Case Presentation
A 68-year-old woman was presented with a vicious onset of sub confusion, insomnia and visual hallucinations.
Medical History
- The patient had been diagnosed with bipolar disorder after she experienced a manic episode in her late twenties following which she was admitted.
- After this incident, she primarily demonstrated manic and hypomanic episodes.
- Five years before admission, the patient was put on 500 mg lithium carbonate monotherapy following which she had been stable.
Clinical Exam
Her evaluation revealed:
- Neuropsychiatric: Vivid visual hallucinations with onirism and confusion.
- Calcitonin levels: Normal
- Thyroid stimulating hormone: Normal
- Ionogram: Normal
- Azotaemia: Normal
- Creatinine: Normal
- Total serum calcium level: High (127 mg/l)
- Serum parathormone level (PTH): Five times the normal value (380 pg/ml)
- Urine methoxylated derivatives: Negative
Her imaging revealed:
- Electrocardiogram and brain MRI: Normal
- Cervical scan: A right lower parathyroid tumor which was confirmed by the cervical ultrasonography that found a 12 X 8 mm adenoma
Diagnosis
The patient was diagnosed with parathyroid adenoma.
Treatment
- She was administered furosemide (120 mg per 24 hours), zoledronic acid (4 mg in a single dose) and parenteral rehydration.
- Lithium carbonate therapy was discontinued.
Five days after admission,
- Serum calcium level dropped to 93 mg/l and worsening of psychiatric symptoms was observed.
- The patient started demonstrating anxiety, subagitation, visual hallucinations and incoherent speech.
- Urgent parathyroidectomy was performed.
Follow-Up
- The parathyroid hormone levels were monitored consistently on day 2, 5 7, 15 and again one month later.
- Postoperative outcome was favourable