Acute pancreatitis as the presenting manifestation of primary hyperparathyroidism due to parathyroid adenoma

Acute pancreatitis (AP) is most commonly associated with gallstones or alcohol use, while hypercalcemia due to primary hyperparathyroidism (PHPT) represents a less frequent but clinically relevant etiology. We present the case of a 61-year-old man who was admitted with acute epigastric pain and elevated serum pancreatic enzymes. Imaging revealed diffuse pancreatic edema with small peripancreatic fluid collections but no gallstones or biliary abnormalities. Further evaluation demonstrated significant hypercalcemia with elevated parathyroid hormone levels, consistent with PHPT. Neck ultrasound and Technetium-99m sestamibi scintigraphy identified a right inferior parathyroid adenoma. The patient was treated with intravenous fluids, bisphosphonates, diuretics, and supportive therapy for AP, resulting in rapid clinical and biochemical improvement. Definitive management with parathyroidectomy led to normalization of calcium levels and a significant intraoperative PTH decrease. At 1-month follow-up, the patient remained asymptomatic without recurrence of hypercalcemia or pancreatitis. This case highlights the pathophysiological link between hypercalcemia and pancreatic injury, where elevated calcium promotes premature activation of digestive enzymes and inflammatory pathways in acinar cells. Although PHPT accounts for a minority of AP cases, recognizing this association is crucial, particularly in patients without typical risk factors. Routine assessment of serum calcium in unexplained pancreatitis facilitates early diagnosis of PHPT and timely surgical intervention, preventing recurrent episodes and improving long-term outcomes.