Preoperative double adenoma upgraded to a triple adenoma after intraoperative sonographic evaluation of the neck Solitary parathyroid adenomas are a common cause of primary hyperparathyroidism (pHPT). Double parathyroid adenomas have a reported frequency of under 12% in primary hyperparathyroidism. We present the case of a 45-year-old female patient admitted with weakness, fatigue, and generalized bone pain. She had been treated for nephrolithiasis five times in the last two years, had high levels of serum calcium and parathyroid hormone, a low level of 25-hydroxy vitamin D, and osteopenia diagnosed by bone densitometry. Neck ultrasonography revealed bilateral parathyroid adenomas, confirmed by technetium-99m-sestamibi scintigraphy on the left. Findings on the right were suspicious, but not diagnostic. The parathyroid hormone washout concentrations were 1989 pg/mL (left) and 2097 pg/mL (right). A bilateral parathyroidectomy was performed. Intraoperative ultrasonography revealed a third retrosternal lesion, which was removed. All three specimens were confirmed as parathyroid adenomas on histological evaluation. Intraoperative neck ultrasonography thus played a crucial role in preventing secondary surgical intervention. Keywords: Double adenoma, intraoperative ultrasonography, parathyroid adenomas, triple adenoma INTRODUCTION Primary hyperparathyroidism (pHPT) resulting from the overproduction of parathyroid hormone (PTH) is associated with hypercalcemia and hypophosphatemia. Most patients with pHPT are diagnosed in- cidentally and do not display classic symptoms such as recurrent nephrolithiasis, peptic ulcers, mental disorders, weakness, or bone and muscle pain. Current guidelines recommend parathyroidectomy for surgical management of pHPT (1). The causes of pHPT include solitary adenoma (80%-85%), multi-gland hyperplasia (15%), and rarely, carcinoma (1%). Double adenomas have been found in 3%-12% of pa- tients undergoing surgery for pHPT. Other rare causes include double and ectopic adenomas (2-5). CASE PRESENTATION A 45-year-old female patient was referred to Bülent Ecevit University Hospital, Department of Urology for evaluation of an adrenal incidentaloma. She had been diagnosed with bilateral adrenal adenomas by abdominal computerized tomography during an evaluation of renal colic episodes one month previ- ously. She was not aware of any hypercalcemia, but had generalized bone pain, muscle weakness, and fatigue, together with the history of recurrent nephrolithiasis fve times in the past two years that was managed by means of extracorporeal shock wave lithotripsy. She has had no history of head or neck irra- diation, thyroid problems, pancreatitis, or any family history of multiple endocrine neoplasia syndromes, or parathyroid or calcium disorders. She had type 2 diabetes mellitus that was controlled by sitagliptin- metformin therapy. Patient’s physical examination revealed nothing signifcant. Biochemical investigations revealed the following: serum calcium, 12.3 mg/dL (normal range, 8.8-10.6 mg/dL); phosphorus, 2.9 mg/dL (normal range, 2.4-5.1 mg/dL); albumin, 4.1 g/dL (normal range, 3.5-5.3 g/dL); PTH, 237 pg/mL (normal range, 12-88 pg/mL); glomerular fltration rate, 75 mL/min/m2; alkaline phosphatase, 99 IU/L; 25-hydroxy vitamin D, 6.4 ng/mL (normal range, 30-100 ng/mL); 24-h urine calci- um, 483 mg/day. Other laboratory examination results were within normal ranges (Table 1). The analysis of the adrenal mass was consistent with benign adenomas. Renal ultrasonography (USG) demonstrated bilateral nephrolithiasis. Bone densitometry measurements revealed that she had osteopenia, with a T score of −1.2. Two smooth, ovoid, hypoechoic lesions with sonographic features of parathyroid adenoma were observed in the neck ultrasonography. . The lesions were measured 15×11×8 mm on the right and 18×12×7 mm on the left (Figure 1). A technetium-99m- sestamibi scan of the left lower lobe of the thyroid confrmed the ultrasonography fndings. However, uptake by the lesion on the right side was suspicious, but not diagnostic of an adenoma (Figure 2). Analysis of the washout from ultrasound-guided fne-needle aspiration of the suspected lesions dem- 1 Department of Endocrinology and Metabolism, Bülent Ecevit University School of Medicine, Zonguldak, Turkey 2 Department of Internal Medicine, Bülent Ecevit University School of Medicine, Zonguldak, Turkey 3 Department of General Surgery, Bülent Ecevit University School of Medicine, Zonguldak, Turkey 4 Department of Nuclear Medicine, Bülent Ecevit University School of Medicine, Zonguldak, Turkey This study was presented at the 17 th European Congress of Endocrinology, 16-20 May 2015, Dublin, Ireland. Address for Correspondence Dilek Arpacı e-mail: drarpaci@gmail.com Received: 12.06.2015 Accepted: 09.09.2015 Available Online Date: 03.01.2018 ©Copyright 2018 by Turkish Surgical Association Available online at www.turkjsurg.com Fatih Kuzu 1 , Dilek Arpacı 1 , Güldeniz Karadeniz Çakmak 3 , Rabia Uslu 4 , Ali Uğur Emre 3 , Sevil Uygun İlikhan 2 , Mehmet Çabuk 4 , Taner Bayraktaroğlu 1 ABSTRACT Turk J Surg 2018 DOI: 10.5152/UCD.2015.3244 Cite this paper as: Kuzu F, Arpacı D, Karadeniz Çakmak G, Uslu R, Emre AU, Uygun İlikhan S, Çabuk M, Bayraktaroğlu T. Preoperative double adenoma upgraded to a triple adenoma after intraoperative sonographic evaluation of the neck. Turk J Surg 2018; DOI: 10.5152/ UCD.2015.3244 Case Report