Lithium-associated primary hyperparathyroidism complicated by nephrogenic diabetes insipidus
Nihat Aksakal1, Candaş Erçetin2, Beyza Özçınar1, Ferihan Aral3, Yeşim Erbil1
1Department of General Surgery, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
2Department of General Surgery, Bağcılar Training and Research Hospital, İstanbul, Turkey
3Department of Endocrinology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
Abstract
Lithium-associated hyperparathyroidism is the leading cause of hypercalcemia in lithium-treated patients. Lithium may lead to exacerbation of pre-existing primary hyperparathyroidism or cause an increased set-point of calcium for parathyroid hormone suppression, leading to parathyroid hyperplasia. Lithium may cause renal tubular concentration defects directly by the development of nephrogenic diabetes insipidus or indirectly by the effects of hypercalcemia. In this study, we present a female patient on long-term lithium treatment who was evaluated for hypercalcemia. Preoperative imaging studies indicated parathyroid adenoma and multinodular goiter. Parathyroidectomy and thyroidectomy were planned. During the postoperative course, prolonged intubation was necessary because of agitation and delirium. During this period, polyuria, severe dehydration, and hypernatremia developed, which responded to controlled hypotonic fluid infusions and was unresponsive to parenteral desmopressin. A diagnosis of nephrogenic diabetes insipidus was apparent. A parathyroid adenoma and multifocal papillary thyroid cancer were detected on histopathological examination. It was thought that nephrogenic diabetes insipidus was masked by hypercalcemia preoperatively. A patient on lithium treatment should be carefully followed up during or after surgery to prevent life-threatening complications of previously unrecognized nephrogenic diabetes insipidus, and the possibility of renal concentrating defects on long-term lithium use should be sought, particularly in patients with impaired consciousness.
Keywords: Lithium, nephrogenic diabetes insipidus, hyperparathyroidism
The patients were informed about all surgical and invasive procedures before surgery and during follow up. They were also expected to sign an form of approval.
Externally peer-reviewed.
Concept - Y.E., C.E., N.A., B.Ö., F.A.; Design - Y.E., C.E., N.A., B.Ö., F.A.; Supervision - Y.E., C.E., N.A., B.Ö., F.A.; Funding - Y.E., C.E., B.Ö.; Materials - Y.E., C.E., N.A.; Data Collection and/or Processing - Y.E., C.E., N.A.; Analysis and/or Interpretation - Y.E., C.E., B.Ö., F.A.; Literature Review - Y.E., C.E., F.A., N.A.; / Writer - Y.E., C.E., F.A.; Critical Review - Y.E., C.E., N.A., B.Ö.
No conflict of interest was declared by the authors.
The authors declared that this study has received no financial support.