Atypical Presentation of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) typically presents with a spectrum of symptoms, including neuropsychiatric manifestations such as anxiety, depression, confusion, and, in severe cases, coma. While psychiatric symptoms are not uncommon in PHPT, acute psychosis is a rare presentation. In such cases, immediate control of serum calcium levels is crucial, and emergency parathyroidectomy may be required if medical management alone fails to control hypercalcemia. A middle-aged female was initially evaluated in the endocrine clinic for newly diagnosed asymptomatic PHPT and was scheduled for elective parathyroidectomy. However, she subsequently presented to the hospital with acute psychosis and elevated serum calcium levels. Despite aggressive intravenous fluid resuscitation and bisphosphonate therapy, her calcium levels and psychiatric symptoms did not improve. She underwent an emergency parathyroidectomy, during which three parathyroid adenomas were identified and removed. Postoperatively, her psychosis resolved, and her serum calcium levels normalized. Genetic testing later ruled out Multiple Endocrine Neoplasia (MEN) syndrome. Multiple parathyroid adenomas represent a rare but important subset of primary hyperparathyroidism. In cases with unusual presentations such as acute psychosis, prompt surgical intervention is essential, as it can lead to the rapid resolution of both hypercalcemia and neuropsychiatric symptoms. Genetic testing for MEN syndromes should be considered in cases of multiple adenomas to ensure appropriate follow-up and management.