Complications Encountered with Non-adherence to Regular Follow-up in the Long-term Medical Management of Hyperparathyroidism

Primary hyperparathyroidism is the third most commonly encountered endocrine disorder after diabetes and thyroid diseases. There has been a constant debate between medical and surgical management of the disorder. Guidelines clearly indicate surgical management over medical management in symptomatic patients and asymptomatic patients below 50 years of age. The problem is identification of symptoms can be difficult as there is a large overlap in the presentation of symptomatic and asymptomatic patients. Here, a 74-year-old veteran presented with scrotal edema and a perineal abscess. He had urinary incontinence secondary to urological procedures which were done for nephrolithiasis, which were detected incidentally on imaging. He had multiple vertebral compression fractures and required referral to neurosurgery. He had worsening renal function and cognitive impairment. On review of his medical records he was found to have a long-standing history of medically managed hyperparathyroidism, which was complicated due to non-compliance to follow-up outpatient visits. He constantly declined elective parathyroidectomy but unfortunately had to undergo several other invasive procedures with multiple hospital visits due to the complications of hyperparathyroidism. Safe medical management of hyperparathyroidism requires a religious follow-up and compliance to outpatient visits. He was started on Denosumab which we attribute to be contributory to his skin infections although evidence to support the same is insufficient.