Bilateral Staghorn Calculi and Urosepsis as Uncommon Presentations of Primary Hyperparathyroidism

Bilateral Staghorn Calculi and Urosepsis as Uncommon Presentations of Primary Hyperparathyroidism | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Bilateral Staghorn Calculi and Urosepsis as Uncommon Presentations of Primary Hyperparathyroidism Eder Luna-Ceron, Venkata Abhilash Muthineni, Eyoab Massebo, Lakshmi Prasanna Vaishnavi Kattamuri, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4499623/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Primary hyperparathyroidism (PHPT) is a prevalent endocrine disorder characterized by excessive parathyroid hormone (PTH) secretion, traditionally associated with hypercalcemia and consequential skeletal and renal complications. While the typical manifestations of PHPT are well-documented, instances of its co-occurrence with bilateral staghorn calculi are infrequently reported. Case presentation: We present the case of a 64-year-old Hispanic female who presented with abdominal pain and sepsis. Subsequent investigations revealed bilateral staghorn calculi on abdominal computed tomography. Metabolic profiling demonstrated hypercalcemia (10.8 mmol/L), elevated intact PTH levels (132.3 pg/mL), normal phosphorus (2.6 mmol/L), and vitamin D levels (43.5 IU). Urinary cultures isolated extended spectrum beta-lactamase (ESBL) E. coli, and seven days of Ertapenem was administered. Suspecting PHPT, a parathyroid 14-sestamibi single photon emission computed tomography (SPECT) was performed, disclosing a 6 mm right inferior parathyroid mass indicative of a parathyroid adenoma. Initiation of Cinacalcet therapy resulted in a prompt decline in serum calcium levels within 48 hours. The patient was planned for surgical intervention involving parathyroidectomy and bilateral nephrolithotomy. Conclusions This case highlights the importance of comprehensive metabolic evaluation for patients presenting with bilateral staghorn calculi, emphasizes the need for a timely and tailored approach to urological and endocrinological management. Primary hyperparathyroidism staghorn calculi cinacalcet urosepsis Figures Figure 1 Figure 2 Background Primary hyperparathyroidism (PHPT) is a common endocrinological condition characterized by excessive uncontrolled production of parathyroid hormone (PTH) 1 . This disorder is characterized by the presence of hypercalcemia, leading to skeletal and renal complications 2 . In 85% of the cases, PHPT is caused by a single parathyroid adenoma, while 14% are associated with parathyroid hyperplasia and a minimal proportion (1%) to parathyroid carcinoma 3 . In this regard, parathyroid hyperproliferation results in overproduction of PTH, leading to increased calcium reabsorption in renal tubules, increased synthesis of calcitriol, increased urinary excretion of phosphorus, and upregulated bone resorption 3 , 4 . These metabolic alterations lead to the development of several manifestations, including nephrolithiasis, chronic kidney disease (CKD), hypercalciuria, and osteoporosis 1 , 4 , 5 . Although historically, this condition has been associated with these clinical manifestations, in recent years, new diagnostic tools have made significant epidemiological shifts, allowing the diagnosis of this condition in asymptomatic patients 2 , 3 . Several studies have shown that in developed countries, the incidence of nephrolithiasis and osteitis fibrosa cystica in patients diagnosed with PHPT has decreased to 23% and 5%, respectively 6 – 8 . Staghorn calculi are large renal stones that usually fill the surface of renal pelvis and calyces 9 . These stones are typically composed of struvite and calcium-phosphorus 9 . Struvite stones are usually associated with repetitive urinary tract infections (UTIs) by urease-producing pathogens 10 . Pathogens that produce urease enzymes split urinary urea into ammonia, hydrolyzed to bicarbonate and ammonium 11 . Conversely, calcium phosphorus stones are usually associated with calcium deposits due to hypercalcemia or hypercalciuria 10 . Many cases of staghorn calculi are unilateral; however, in less than 15% of the cases, both kidneys can be involved 9 . Patients with staghorn calculi findings should prompt metabolic and infectious evaluation to understand the etiology, as most of these stones have been associated with underlying systemic comorbidities 9 , 10 . Although the relationship between nephrolithiasis and PHPT is well known 1 , bilateral staghorn calculi in patients with PHPT have been scarcely reported 12 – 14 . In this article, we report the case of a 64-year-old female presenting with urosepsis and bilateral staghorn calculi in which further approach revealed the presence of PHPT. Case Presentation 64-year-old Hispanic female with past medical history of hypertension, hyperlipidemia, and prediabetes. The patient presented with the presence of bilateral lower quadrant colic pain with radiation to back associated with 5 episodes of emesis that started 24 hours prior to admission. She reported the presence of chills but no dysuria or hematuria. Upon admission, she was febrile (38.8 ºC), tachycardic (102 bpm), and hypertensive (170/93 mmHg). Physical examination revealed renal angle tenderness. Laboratory workup at admission is summarized in Table 1 . Patient laboratories revealed neutrophilic leukocytosis, urinalysis was concerning for UTI with positive nitrites and leukocyte esterase as well as significant bacteriuria and pyuria. Acute phase reactants (procalcitonin and c-reactive protein) were also significantly elevated. The patient was also found to have hypercalcemia (10.7 mmol) present with correction with albumin levels. Table 1 Laboratory workup upon patient admission. Units of measurement are presented along with the laboratory results. Abbreviations: WBC: White blood cell count; HCT: Hematocrit; PTH: Parathyroid hormone. Parameter Result Reference range WBC 16.1 U x 10 9 /L 4.5 to 11.0 x 109/L Hemoglobin 13.5 g/dL 12.0 to 16.0 g/dL HCT 40.2% 36–48% Platelet Count 340 U x 10 9 /L 150 to 400 x 109/L Neutrophil Count 13.4 U x 10 9 /L 2.5 to 6 x 10 9 /L Sodium serum levels 136 mmol/L 135 to 145 mmol/L Potassium serum levels 3.5 mmol/L 3.5 to 5.2 mmol/L Chloride serum levels 107 mmol/L 96 to 106 mmol/L Calcium serum levels 10.8 mmol/L 8.5 to 10.2 mg/dL Ionized calcium levels 2.1 mmol/L 1.16 to 1.31 mmol/L Phosphorus serum levels 2.6 mmol/L 2.8 to 4.5 mmol/L Albumin serum levels 3.9 g/dL 3.4 to 5.4 g/dL Lactate levels 2.4 mmol/L < 2 mmol/L Bicarbonate levels 16 mmol/L 23 to 29 mmol/L Creatinine serum levels 0.7 mg/dL 0.6 to 1.1 mg/dL Urinalysis Bacteria 4+, Nitrite Positive, Leukocyte Esterase Positive. Negative for bacteria, nitrite, and leukocyte esterase Urine calcium excretion 350 mg/24 hours 100–300 mg/24 hrs Procalcitonin 3 µg/L < 0.05 µg/L C-reactive protein 8 mg/dL 0.3 to 1.0 mg/dL PTH Intact 132.3 pg/mL 15 to 65 pg/mL Vitamin D serum levels 43.5 ng/mL 20 and 40 ng/mL Given the suspicion of urolithiasis from the physical examination and sepsis from likely urinary origin, the patient underwent computed tomography (CT) of the abdomen without contrast (Fig. 1 A-B) that demonstrated the presence of bilateral renal calculi, the largest of which were staghorn calculi near both ureteropelvic junctions with associated hydronephrosis mainly on the left kidney. We empirically started the patient on ertapenem given her history of extended spectrum beta-lactamase (ESBL) positive E. Coli UTI. Urology recommended to undergo cystoscopy with insertion of a left ureteral stent. The patient underwent the procedure with no acute complications. Clinical features and lab parameters significantly improved after 48 hours of antibiotic therapy. Urinary cultures drawn at this admission grew ESBL-positive E. Coli. The infectious diseases specialist recommended a seven-day regimen of intravenous ertapenem, followed by an additional seven days of oral Trimethoprim-Sulfamethoxazole. Regarding her hypercalcemia, the patient was managed with intravenous fluids and was started on oral Cinacalcet 30 mg two times per day. Further approach revealed the presence of elevated intact PTH (155.2 pg/mL) with normal phosphorus serum levels (2.6 mmol/L) and normal vitamin D serum levels (43.5 IU). Dual-energy X-ray absorptiometry (DEXA) bone scan revealed the presence of osteoporosis at the femoral neck (T-score = -2.8) and lumbar spine (T-score = -2.9). As primary hyperparathyroidism was suspected, a parathyroid 14-sestamibi single photon emission computed tomography (SPECT) was performed and revealed the presence of a right inferior parathyroid adenoma (Fig. 2 A-F). Considering the necessity for surgery, a consultation with endocrine surgery was sought, and a neck CT scan with a parathyroid protocol was planned in anticipation of the upcoming parathyroidectomy. However, the calcium levels normalized after 72 hours of Cinacalcet therapy. The patient completed the necessary duration of antibiotics and was discharged to follow up with endocrine surgery for parathyroidectomy and further management of urolithiasis by the urology department. Discussion and Conclusions We presented a case of a female patient with findings of bilateral renal staghorn calculi and mild sepsis. As previously described, patients found to have staghorn calculi should prompt evaluation to exclude recurrent UTIs or metabolic disturbances causing this clinical presentation, including serum ionized calcium, serum phosphorus levels, and PTH levels to evaluate for PHPT, serum creatinine levels to evaluate renal function as well as serum bicarbonate and electrolytes to evaluate for renal tubular acidosis 10 . Interestingly, the approach of this case revealed the presence of hypercalcemia and significantly elevated PTH intact levels without the presence of metabolic acidosis. PTH-dependent hypercalcemia narrows possible differential diagnosis. Differentials at this time pointed to PHPT and conditions that mimic PHPT as familial hypocalciuric hypercalcemia (FHH) 1 , 3 . Other conditions such as malignancy, vitamin D toxicity, granulomatous disorders, or multiple myeloma were excluded as the patient had elevated intact PTH with normal vitamin D levels and normal renal function 15 . FHH suspicion was low in our patient as other family members did not show any history of urolithiasis or hypercalcemia, and urine calcium excretion was greater than 200 mg daily 15 . The initial approach for suspected PHPT requires the performance of Parathyroid 14-sestamibi SPECT 1 . In the case of our patient, this imaging modality was concordant in the presence of a mass compatible with a parathyroid adenoma in the right lower parathyroid gland. These findings pointed towards the diagnosis of PHPT. This underlying comorbidity explained the presence of bilateral large staghorn calculi. In this regard, elevated levels of PTH enhance calcium release from bone into the bloodstream. At the same time, PTH increases the renal excretion of calcium into the urine, favoring deposit and sedimentation in the urinary tract and the development of stones 3 . Patients with PHPT can benefit from medical and surgical therapy 16 . Several studies have shown calcimimetics's efficacy and safety in managing PHPT 16 , 17 . Calcimimetics such as cinacalcet act by activation of the calcium-sensing receptors (CaSR) present in the chief cells at the parathyroid glands 18 . Activation of CaSR downtrends the synthesis and release of PTH, thus mitigating the calcium and phosphorus products in the bloodstream field 18 . Multicenter, randomized, double-blind clinical trials have shown that cinacalcet was able to normalize serum calcium levels in more than 70% of the subjects with PHPT even after 52 weeks of follow-up 16 , 17 . The same trials also achieved a significant reduction of 37% in PTH levels compared to the placebo 16 , 17 . Both retrospective and prospective open-label studies have demonstrated that cinacalcet at doses ranging from 30 to 60 mg can significantly downtrend serum calcium and PTH levels with no significant side effects 16 , 17 . Arthralgia, myalgia, diarrhea, and nausea are common adverse effects, but research shows that less than 20% of patients experience them 17 . Other medications can also be used, including oral bisphosphonates and denosumab, which can help improve mineral bone density and alleviate hypercalcemia. However, their effects on PTH release are minimal 19 . Given cinacalcet's safety and effectiveness, we decided to start this therapy in our patient, with positive effects present after 48 hours of management. Surgical management is the cornerstone of managing PHPT in patients with recurrent nephrolithiasis or decreased bone mineral density. Notably, our patient presented with significant nephrolithiasis and osteoporosis confirmed by DEXA scan 19 . Successful parathyroidectomy results in permanent normalization of calcium and PTH levels and significant improvement in BMD 19 , 20 . Positive outcomes in recurrent nephrolithiasis and major fractures have also been observed 20 . Current guidelines recommend surgical management in patients with symptomatic PHPT 19 , 20 . Hence, we referred our patient to endocrine surgery in preparation for parathyroidectomy. The presentation of patients with PHPT and bilateral staghorn calculi remains scarce. To the best of our knowledge, only three cases with this presentation have been previously reported in the literature. The clinical presentation and hallmarks of these cases are summarized in Table 2 . Table 2 Clinical presentation, diagnostic approach, and management of previously published cases of bilateral staghorn calculi as presentation of primary hyperparathyroidism. Abbreviations: Ca + 2: Calcium; SPECT: Single photon emission computed tomography; PTH Parathyroid hormone. Reference Age and Sex Clinical Findings Management Gupta, et al. 12 35-years-old female Bilateral staghorn calculi presenting as flank pain and hematuria. Elevated PTH, Elevated ionized Ca + 2 level. Normal Vitamin D levels. Right lower parathyroid adenoma present on ultrasound. Minimally invasive parathyroidectomy. Left nephrolithotomy with ureteral stent placement. George & Banerji 13 38-years-old female Bilateral staghorn calculi and brown tumor in the right thumb, presenting with hand and abdominal chronic pain. Elevated ionized Ca + 2 levels. Elevated PTH levels. Normal Vitamin D levels. Normal phosphorus levels. Left lower parathyroid adenoma present on SPECT. Percutaneous nephrolithotomy and parathyroidectomy. Pramono et al. 14 28-years-old female Recurrent bilateral retroperitoneal pain. Presence of bilateral staghorn calculi. Elevated ionized Ca + 2, Elevated intact PTH levels. Right lower parathyroid adenoma on SPECT. Three times extracorporeal shock wave lithotripsy. Parathyroidectomy and nephrolithotomy. Remarkably, these cases were observed in female patients, which is in concordance with several cohort studies. Interestingly, in the case published by George & Banerji, findings of bilateral staghorn calculi were present alongside a brown tumor, which is a lesion that results from the chronic turnover of bone calcium and active proliferation of fibrous tissue in patients with PHPT 13 . In agreement with our management, all the cases priorly described were managed initially by controlling hypercalcemia, followed by parathyroidectomy, and then managed with percutaneous nephrolithotomy 12 – 14 . In conclusion, our case report underscores the importance of a comprehensive evaluation for patients presenting with bilateral staghorn calculi. The diagnostic approach should involve directed assessments to rule out recurrent UTI or metabolic disturbances that may contribute to the clinical presentation. Essential laboratory investigations, including serum ionized calcium, serum phosphorus, PTH levels, serum creatinine, serum bicarbonate, and electrolytes, are integral in assessing renal function and identifying potential PHPT or renal tubular acidosis. Furthermore, our findings highlight the significance of Parathyroid 14-sestamibi SPECT as the imaging modality of choice for suspected PHPT. Despite PHPT often being asymptomatic, early detection through targeted evaluations is crucial, as symptomatic cases necessitate prompt intervention. For those with symptomatic PHPT, parathyroidectomy emerges as the preferred treatment option. In cases where surgery may be contraindicated or as a preparatory measure for parathyroidectomy, calcimimetics such as cinacalcet are valuable therapeutic alternatives. This comprehensive approach to diagnosis and management ensures a tailored and effective strategy for patients with PHPT. Lastly, our case discussion sheds light on the optimal treatment approach for bilateral staghorn calculi, emphasizing the significance of nephrolithotomy as the treatment of choice. This conclusive summary reinforces the need for a multidisciplinary and individualized approach to managing patients with this condition, ensuring timely and appropriate interventions based on thorough diagnostic assessments. Abbreviations Ca + 2 Calcium CaSR Calcium-sensing receptors CKD Chronic kidney disease DEXA Dual-energy X-ray absorptiometry FHH Familial hypocalciuric hypercalcemia CT Computed tomography ESBL Extended spectrum beta-lactamase PHPT Primary hyperparathyroidism PTH Parathyroid hormone SPECT Single photon emission computed tomography UTI Urinary tract infection Declarations Disclosure summary: The authors declare no conflicts of interest. Competing interests The authors declare no financial and non-financial conflicts of interest. Consent to publish The authors confirm that written informed consent has been obtained from the involved patient for this information to be published in this case report. All personal information of the patient has been completely removed. Funding This work was supported by the Graduate Student Fellowship from the National Council of Science and Technology of Mexico (CONACYT). Author Contribution ELC was in charge of Patient care, conceptualization, original draft writing and editing, literature review and figure preparation. AVM was in charge of original draft writing and editing, literature review. EM was in charge of manuscript revision and editing, patient care supervision. MPA was in charge of manuscript revision and editing, patient care supervision. LPVK was in charge of manuscript revision and editing, patient care . CD was in charge of manuscript revision and editing, patient care supervision, conceptualization, methodological review. All authors agreed on the final version of the manuscript. Acknowledgement We thank the laboratory department of University Medical Center of El Paso for their contributions for the sample analyses employed in the diagnostic approach of the patient. Data availability The datasets generated and/or analyzed during the current study are available upon contact of the corresponding author. References Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol. 2018;14(2):115–25. 10.1038/nrendo.2017.104 . Press DM, Siperstein AE, Berber E, et al. The prevalence of undiagnosed and unrecognized primary hyperparathyroidism: A population-based analysis from the electronic medical record. Surgery. 2013;154(6):1232–8. 10.1016/j.surg.2013.06.051 . Bilezikian JP, Cusano NE, Khan AA, Liu JM, Marcocci C, Bandeira F. Primary hyperparathyroidism. Nat Rev Dis Primer. 2016;2(1):16033. 10.1038/nrdp.2016.33 . Dandurand K, Ali DS, Khan AA. Primary Hyperparathyroidism: A Narrative Review of Diagnosis and Medical Management. J Clin Med. 2021;10(8). 10.3390/jcm10081604 . Shelley Pallan MO, Rahman, Aliya A, Khan. Diagnosis and management of primary hyperparathyroidism. BMJ. 2012;344:e1013. 10.1136/bmj.e1013 . Bilezikian JP, Silverberg SJ. Asymptomatic Primary Hyperparathyroidism. N Engl J Med. 2004;350(17):1746–51. 10.1056/NEJMcp032200 . Lowe H, McMahon D, Rubin M, Bilezikian J, Silverberg S. Normocalcemic primary hyperparathyroidism: further characterization of a new clinical phenotype. J Clin Endocrinol Metab. 2007;92(8):3001–5. Yeh MW, Ituarte PH, Zhou HC, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab. 2013;98(3):1122–9. Torricelli FCM, Monga M. Staghorn renal stones: what the urologist needs to know. Int Braz J Urol. 2020;46(6):927–33. 10.1590/s1677-5538.ibju.2020.99.07 . Terry RS, Preminger GM. Metabolic evaluation and medical management of staghorn calculi. Asian J Urol. 2019;7:122–9. Flannigan R, Choy WH, Chew B, Lange D. Renal struvite stones—pathogenesis, microbiology, and management strategies. Nat Rev Urol. 2014;11(6):333–41. 10.1038/nrurol.2014.99 . Gupta M, Khan H, Nijhawan VS, Gaba S, Gupta M. Revisiting a Case of Parathyroid Adenoma With Bilateral Staghorn Calculus. Cureus. 2020;12(5). George AJP, Banerji JS. Brown tumor and staghorn calculi in primary hyperparathyroidism. Urology. 2013;82(2):e13–4. Pramono LA, Larasati D, Yossy Y, Harbuwono DS, Soebardi S. Recurrent bilateral staghorn stones as a manifestation of primary hyperparathyroidism due to parathyroid adenoma. Acta Med Indones. 2015;47(4). Minhas PS, Virdi JK. Hypercalcemia in inpatient setting: Diagnostic approach and management. Curr Emerg Hosp Med Rep. 2017;5:5–10. Ng CH, Chin YH, Tan MHQ, et al. Cinacalcet and primary hyperparathyroidism: systematic review and meta regression. Endocr Connect. 2020;9(7):724–35. 10.1530/EC-20-0221 . Chandran M, Bilezikian JP, Lau J, et al. The efficacy and safety of cinacalcet in primary hyperparathyroidism: a systematic review and meta-analysis of randomized controlled trials and cohort studies. Rev Endocr Metab Disord. 2022;23(3):485–501. 10.1007/s11154-021-09694-6 . Hou YC, Zheng CM, Chiu HW, Liu WC, Lu KC, Lu CL. Role of Calcimimetics in Treating Bone and Mineral Disorders Related to Chronic Kidney Disease. Pharmaceuticals. 2022;15(8). 10.3390/ph15080952 . Bilezikian JP, Brandi ML, Eastell R et al. Guidelines for the Management of Asymptomatic Primary Hyperparathyroidism: Summary Statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561–3569. 10.1210/jc.2014-1413 . Pretorius M, Lundstam K, Hellström M, et al. Effects of Parathyroidectomy on Quality of Life: 10 Years of Data From a Prospective Randomized Controlled Trial on Primary Hyperparathyroidism (the SIPH-Study). J Bone Min Res. 2021;36(1):3–11. 10.1002/jbmr.4199 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4499623","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":311028437,"identity":"b8e3e8c0-d8d8-4bab-84f4-54f2ea43d446","order_by":0,"name":"Eder Luna-Ceron","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYDACdijND8TMEGYCAS1QZQySbcykajE4RqwWfmYeswc/amzyje/3H5Mu+GPHwM+eY4BXi2Qzj7lhz7E0y23HmNmkZ7YlM0j2vMGvxeAwj5kEb8NhAzOQFt6GAwwGNwjYYg/UIvm34b+BcRtQC8+fAwz2hLQYAP0CMtzAgA2khQ1oiwQBLRKH2cqkZY4lG0gcSza25m1L5pE486wArxb+9uZtkm9q7Az4mw8+vM3zx06Ovz15A14tGICHNOWjYBSMglEwCrACAJQzOAoJkdhhAAAAAElFTkSuQmCC","orcid":"","institution":"Texas Tech University Health Sciences Center","correspondingAuthor":true,"prefix":"","firstName":"Eder","middleName":"","lastName":"Luna-Ceron","suffix":""},{"id":311028438,"identity":"4abadacc-fa1f-4e5b-ab3f-9f53b2f82d21","order_by":1,"name":"Venkata Abhilash Muthineni","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Venkata","middleName":"Abhilash","lastName":"Muthineni","suffix":""},{"id":311028439,"identity":"6d1c661c-ed93-4e5d-82c3-d39c7812d8f8","order_by":2,"name":"Eyoab Massebo","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Eyoab","middleName":"","lastName":"Massebo","suffix":""},{"id":311028440,"identity":"a8211fd3-7b5b-486e-a5d8-a98bc5fc739f","order_by":3,"name":"Lakshmi Prasanna Vaishnavi Kattamuri","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Lakshmi","middleName":"Prasanna Vaishnavi","lastName":"Kattamuri","suffix":""},{"id":311028441,"identity":"569aa8c2-36e8-4ee4-a320-97e5afcb98c0","order_by":4,"name":"Mateo Porres-Aguilar","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Mateo","middleName":"","lastName":"Porres-Aguilar","suffix":""},{"id":311028442,"identity":"e4fcb1ef-522e-451c-be63-8b015f4720d0","order_by":5,"name":"Claudia Didia","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Claudia","middleName":"","lastName":"Didia","suffix":""}],"badges":[],"createdAt":"2024-05-30 01:24:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4499623/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4499623/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58316647,"identity":"7837cd13-acc4-438a-9a04-d90521a33f41","added_by":"auto","created_at":"2024-06-13 21:08:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1028854,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography of the abdomen without contrast reveals bilateral hyperdense structures compatible with staghorn calculi (yellow arrows). A. Focus on the right kidney. B. Focus on the right kidney.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4499623/v1/abdbdf539b200f46fa49f9fa.png"},{"id":58316649,"identity":"f09aa671-8b44-4c9b-9329-4142de7f0705","added_by":"auto","created_at":"2024-06-13 21:08:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1080309,"visible":true,"origin":"","legend":"\u003cp\u003eParathyroid 14-sestamibi single photon emission computed tomography (SPECT) revealed the presence of a right inferior parathyroid adenoma (yellow arrows). A. A. Lateral right view early scan. B. Anterior view early scan. C. Lateral left view early scan. D. Lateral right view wash-out scan. E. Anterior view wash-out scan. F. Lateral left view wash-out scan.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4499623/v1/c0af79d06686bcf81b4fa6d1.png"},{"id":83037346,"identity":"bdb0d672-d470-46fb-9b64-eea63b790c4d","added_by":"auto","created_at":"2025-05-19 10:08:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2683777,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4499623/v1/02249830-ff64-44ef-9f77-acd25ba2fcfd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bilateral Staghorn Calculi and Urosepsis as Uncommon Presentations of Primary Hyperparathyroidism","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary hyperparathyroidism (PHPT) is a common endocrinological condition characterized by excessive uncontrolled production of parathyroid hormone (PTH)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. This disorder is characterized by the presence of hypercalcemia, leading to skeletal and renal complications\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. In 85% of the cases, PHPT is caused by a single parathyroid adenoma, while 14% are associated with parathyroid hyperplasia and a minimal proportion (1%) to parathyroid carcinoma\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In this regard, parathyroid hyperproliferation results in overproduction of PTH, leading to increased calcium reabsorption in renal tubules, increased synthesis of calcitriol, increased urinary excretion of phosphorus, and upregulated bone resorption\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. These metabolic alterations lead to the development of several manifestations, including nephrolithiasis, chronic kidney disease (CKD), hypercalciuria, and osteoporosis\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Although historically, this condition has been associated with these clinical manifestations, in recent years, new diagnostic tools have made significant epidemiological shifts, allowing the diagnosis of this condition in asymptomatic patients\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Several studies have shown that in developed countries, the incidence of nephrolithiasis and osteitis fibrosa cystica in patients diagnosed with PHPT has decreased to 23% and 5%, respectively\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eStaghorn calculi are large renal stones that usually fill the surface of renal pelvis and calyces\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. These stones are typically composed of struvite and calcium-phosphorus\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Struvite stones are usually associated with repetitive urinary tract infections (UTIs) by urease-producing pathogens\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Pathogens that produce urease enzymes split urinary urea into ammonia, hydrolyzed to bicarbonate and ammonium\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Conversely, calcium phosphorus stones are usually associated with calcium deposits due to hypercalcemia or hypercalciuria\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Many cases of staghorn calculi are unilateral; however, in less than 15% of the cases, both kidneys can be involved\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Patients with staghorn calculi findings should prompt metabolic and infectious evaluation to understand the etiology, as most of these stones have been associated with underlying systemic comorbidities\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough the relationship between nephrolithiasis and PHPT is well known\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, bilateral staghorn calculi in patients with PHPT have been scarcely reported\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. In this article, we report the case of a 64-year-old female presenting with urosepsis and bilateral staghorn calculi in which further approach revealed the presence of PHPT.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e64-year-old Hispanic female with past medical history of hypertension, hyperlipidemia, and prediabetes. The patient presented with the presence of bilateral lower quadrant colic pain with radiation to back associated with 5 episodes of emesis that started 24 hours prior to admission. She reported the presence of chills but no dysuria or hematuria. Upon admission, she was febrile (38.8 \u0026ordm;C), tachycardic (102 bpm), and hypertensive (170/93 mmHg). Physical examination revealed renal angle tenderness.\u003c/p\u003e \u003cp\u003eLaboratory workup at admission is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patient laboratories revealed neutrophilic leukocytosis, urinalysis was concerning for UTI with positive nitrites and leukocyte esterase as well as significant bacteriuria and pyuria. Acute phase reactants (procalcitonin and c-reactive protein) were also significantly elevated. The patient was also found to have hypercalcemia (10.7 mmol) present with correction with albumin levels.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory workup upon patient admission. Units of measurement are presented along with the laboratory results. Abbreviations: WBC: White blood cell count; HCT: Hematocrit; PTH: Parathyroid hormone.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference range\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.1 U x 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5 to 11.0 x 109/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5 g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0 to 16.0 g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u0026ndash;48%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e340 U x 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150 to 400 x 109/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutrophil Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4 U x 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5 to 6 x 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135 to 145 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 to 5.2 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChloride serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 to 106 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.8 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5 to 10.2 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIonized calcium levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.16 to 1.31 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhosphorus serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 to 4.5 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4 to 5.4 g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactate levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicarbonate levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 to 29 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7 mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6 to 1.1 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinalysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBacteria 4+, Nitrite Positive, Leukocyte Esterase Positive.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative for bacteria, nitrite, and leukocyte esterase\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine calcium excretion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e350 mg/24 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u0026ndash;300 mg/24 hrs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcalcitonin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 \u0026micro;g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05 \u0026micro;g/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3 to 1.0 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH Intact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132.3 pg/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 to 65 pg/mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVitamin D serum levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.5 ng/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 and 40 ng/mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eGiven the suspicion of urolithiasis from the physical examination and sepsis from likely urinary origin, the patient underwent computed tomography (CT) of the abdomen without contrast (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-B) that demonstrated the presence of bilateral renal calculi, the largest of which were staghorn calculi near both ureteropelvic junctions with associated hydronephrosis mainly on the left kidney.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe empirically started the patient on ertapenem given her history of extended spectrum beta-lactamase (ESBL) positive E. Coli UTI. Urology recommended to undergo cystoscopy with insertion of a left ureteral stent. The patient underwent the procedure with no acute complications. Clinical features and lab parameters significantly improved after 48 hours of antibiotic therapy. Urinary cultures drawn at this admission grew ESBL-positive E. Coli. The infectious diseases specialist recommended a seven-day regimen of intravenous ertapenem, followed by an additional seven days of oral Trimethoprim-Sulfamethoxazole.\u003c/p\u003e \u003cp\u003eRegarding her hypercalcemia, the patient was managed with intravenous fluids and was started on oral Cinacalcet 30 mg two times per day. Further approach revealed the presence of elevated intact PTH (155.2 pg/mL) with normal phosphorus serum levels (2.6 mmol/L) and normal vitamin D serum levels (43.5 IU). Dual-energy X-ray absorptiometry (DEXA) bone scan revealed the presence of osteoporosis at the femoral neck (T-score = -2.8) and lumbar spine (T-score = -2.9).\u003c/p\u003e \u003cp\u003eAs primary hyperparathyroidism was suspected, a parathyroid 14-sestamibi single photon emission computed tomography (SPECT) was performed and revealed the presence of a right inferior parathyroid adenoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-F).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eConsidering the necessity for surgery, a consultation with endocrine surgery was sought, and a neck CT scan with a parathyroid protocol was planned in anticipation of the upcoming parathyroidectomy. However, the calcium levels normalized after 72 hours of Cinacalcet therapy. The patient completed the necessary duration of antibiotics and was discharged to follow up with endocrine surgery for parathyroidectomy and further management of urolithiasis by the urology department.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eWe presented a case of a female patient with findings of bilateral renal staghorn calculi and mild sepsis. As previously described, patients found to have staghorn calculi should prompt evaluation to exclude recurrent UTIs or metabolic disturbances causing this clinical presentation, including serum ionized calcium, serum phosphorus levels, and PTH levels to evaluate for PHPT, serum creatinine levels to evaluate renal function as well as serum bicarbonate and electrolytes to evaluate for renal tubular acidosis\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Interestingly, the approach of this case revealed the presence of hypercalcemia and significantly elevated PTH intact levels without the presence of metabolic acidosis.\u003c/p\u003e \u003cp\u003ePTH-dependent hypercalcemia narrows possible differential diagnosis. Differentials at this time pointed to PHPT and conditions that mimic PHPT as familial hypocalciuric hypercalcemia (FHH)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Other conditions such as malignancy, vitamin D toxicity, granulomatous disorders, or multiple myeloma were excluded as the patient had elevated intact PTH with normal vitamin D levels and normal renal function\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. FHH suspicion was low in our patient as other family members did not show any history of urolithiasis or hypercalcemia, and urine calcium excretion was greater than 200 mg daily\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe initial approach for suspected PHPT requires the performance of Parathyroid 14-sestamibi SPECT\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In the case of our patient, this imaging modality was concordant in the presence of a mass compatible with a parathyroid adenoma in the right lower parathyroid gland. These findings pointed towards the diagnosis of PHPT. This underlying comorbidity explained the presence of bilateral large staghorn calculi. In this regard, elevated levels of PTH enhance calcium release from bone into the bloodstream. At the same time, PTH increases the renal excretion of calcium into the urine, favoring deposit and sedimentation in the urinary tract and the development of stones\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients with PHPT can benefit from medical and surgical therapy\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Several studies have shown calcimimetics's efficacy and safety in managing PHPT\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Calcimimetics such as cinacalcet act by activation of the calcium-sensing receptors (CaSR) present in the chief cells at the parathyroid glands\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Activation of CaSR downtrends the synthesis and release of PTH, thus mitigating the calcium and phosphorus products in the bloodstream field\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMulticenter, randomized, double-blind clinical trials have shown that cinacalcet was able to normalize serum calcium levels in more than 70% of the subjects with PHPT even after 52 weeks of follow-up\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The same trials also achieved a significant reduction of 37% in PTH levels compared to the placebo\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Both retrospective and prospective open-label studies have demonstrated that cinacalcet at doses ranging from 30 to 60 mg can significantly downtrend serum calcium and PTH levels with no significant side effects\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Arthralgia, myalgia, diarrhea, and nausea are common adverse effects, but research shows that less than 20% of patients experience them\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Other medications can also be used, including oral bisphosphonates and denosumab, which can help improve mineral bone density and alleviate hypercalcemia. However, their effects on PTH release are minimal\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Given cinacalcet's safety and effectiveness, we decided to start this therapy in our patient, with positive effects present after 48 hours of management.\u003c/p\u003e \u003cp\u003eSurgical management is the cornerstone of managing PHPT in patients with recurrent nephrolithiasis or decreased bone mineral density. Notably, our patient presented with significant nephrolithiasis and osteoporosis confirmed by DEXA scan\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Successful parathyroidectomy results in permanent normalization of calcium and PTH levels and significant improvement in BMD\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Positive outcomes in recurrent nephrolithiasis and major fractures have also been observed\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Current guidelines recommend surgical management in patients with symptomatic PHPT\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Hence, we referred our patient to endocrine surgery in preparation for parathyroidectomy.\u003c/p\u003e \u003cp\u003eThe presentation of patients with PHPT and bilateral staghorn calculi remains scarce. To the best of our knowledge, only three cases with this presentation have been previously reported in the literature. The clinical presentation and hallmarks of these cases are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical presentation, diagnostic approach, and management of previously published cases of bilateral staghorn calculi as presentation of primary hyperparathyroidism. Abbreviations: Ca\u0026thinsp;+\u0026thinsp;2: Calcium; SPECT: Single photon emission computed tomography; PTH Parathyroid hormone.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge and Sex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eManagement\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGupta, et al.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35-years-old female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBilateral staghorn calculi presenting as flank pain and hematuria. Elevated PTH, Elevated ionized Ca\u0026thinsp;+\u0026thinsp;2 level. Normal Vitamin D levels. Right lower parathyroid adenoma present on ultrasound.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinimally invasive parathyroidectomy. Left nephrolithotomy with ureteral stent placement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeorge \u0026amp; Banerji\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38-years-old female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBilateral staghorn calculi and brown tumor in the right thumb, presenting with hand and abdominal chronic pain. Elevated ionized Ca\u0026thinsp;+\u0026thinsp;2 levels. Elevated PTH levels. Normal Vitamin D levels. Normal phosphorus levels. Left lower parathyroid adenoma present on SPECT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercutaneous nephrolithotomy and parathyroidectomy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePramono et al.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28-years-old female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrent bilateral retroperitoneal pain. Presence of bilateral staghorn calculi. Elevated ionized Ca\u0026thinsp;+\u0026thinsp;2, Elevated intact PTH levels. Right lower parathyroid adenoma on SPECT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThree times extracorporeal shock wave lithotripsy. Parathyroidectomy and nephrolithotomy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRemarkably, these cases were observed in female patients, which is in concordance with several cohort studies. Interestingly, in the case published by George \u0026amp; Banerji, findings of bilateral staghorn calculi were present alongside a brown tumor, which is a lesion that results from the chronic turnover of bone calcium and active proliferation of fibrous tissue in patients with PHPT\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. In agreement with our management, all the cases priorly described were managed initially by controlling hypercalcemia, followed by parathyroidectomy, and then managed with percutaneous nephrolithotomy\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn conclusion, our case report underscores the importance of a comprehensive evaluation for patients presenting with bilateral staghorn calculi. The diagnostic approach should involve directed assessments to rule out recurrent UTI or metabolic disturbances that may contribute to the clinical presentation. Essential laboratory investigations, including serum ionized calcium, serum phosphorus, PTH levels, serum creatinine, serum bicarbonate, and electrolytes, are integral in assessing renal function and identifying potential PHPT or renal tubular acidosis.\u003c/p\u003e \u003cp\u003eFurthermore, our findings highlight the significance of Parathyroid 14-sestamibi SPECT as the imaging modality of choice for suspected PHPT. Despite PHPT often being asymptomatic, early detection through targeted evaluations is crucial, as symptomatic cases necessitate prompt intervention. For those with symptomatic PHPT, parathyroidectomy emerges as the preferred treatment option. In cases where surgery may be contraindicated or as a preparatory measure for parathyroidectomy, calcimimetics such as cinacalcet are valuable therapeutic alternatives. This comprehensive approach to diagnosis and management ensures a tailored and effective strategy for patients with PHPT.\u003c/p\u003e \u003cp\u003eLastly, our case discussion sheds light on the optimal treatment approach for bilateral staghorn calculi, emphasizing the significance of nephrolithotomy as the treatment of choice. This conclusive summary reinforces the need for a multidisciplinary and individualized approach to managing patients with this condition, ensuring timely and appropriate interventions based on thorough diagnostic assessments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCa\u0026thinsp;+\u0026thinsp;2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCalcium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCaSR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCalcium-sensing receptors\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCKD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDEXA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDual-energy X-ray absorptiometry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFHH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamilial hypocalciuric hypercalcemia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExtended spectrum beta-lactamase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary hyperparathyroidism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParathyroid hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPECT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSingle photon emission computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosure summary:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no financial and non-financial conflicts of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003e The authors confirm that written informed consent has been obtained from the involved patient for this information to be published in this case report. All personal information of the patient has been completely removed.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the Graduate Student Fellowship from the National Council of Science and Technology of Mexico (CONACYT).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eELC was in charge of Patient care, conceptualization, original draft writing and editing, literature review and figure preparation. AVM was in charge of original draft writing and editing, literature review. EM was in charge of manuscript revision and editing, patient care supervision. MPA was in charge of manuscript revision and editing, patient care supervision. LPVK was in charge of manuscript revision and editing, patient care . CD was in charge of manuscript revision and editing, patient care supervision, conceptualization, methodological review. All authors agreed on the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the laboratory department of University Medical Center of El Paso for their contributions for the sample analyses employed in the diagnostic approach of the patient.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eThe datasets generated and/or analyzed during the current study are available upon contact of the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWalker MD, Silverberg SJ. Primary hyperparathyroidism. 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J Bone Min Res. 2021;36(1):3\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jbmr.4199\u003c/span\u003e\u003cspan address=\"10.1002/jbmr.4199\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Primary hyperparathyroidism, staghorn calculi, cinacalcet, urosepsis","lastPublishedDoi":"10.21203/rs.3.rs-4499623/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4499623/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrimary hyperparathyroidism (PHPT) is a prevalent endocrine disorder characterized by excessive parathyroid hormone (PTH) secretion, traditionally associated with hypercalcemia and consequential skeletal and renal complications. While the typical manifestations of PHPT are well-documented, instances of its co-occurrence with bilateral staghorn calculi are infrequently reported.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe present the case of a 64-year-old Hispanic female who presented with abdominal pain and sepsis. Subsequent investigations revealed bilateral staghorn calculi on abdominal computed tomography. Metabolic profiling demonstrated hypercalcemia (10.8 mmol/L), elevated intact PTH levels (132.3 pg/mL), normal phosphorus (2.6 mmol/L), and vitamin D levels (43.5 IU). Urinary cultures isolated extended spectrum beta-lactamase (ESBL) E. coli, and seven days of Ertapenem was administered. Suspecting PHPT, a parathyroid 14-sestamibi single photon emission computed tomography (SPECT) was performed, disclosing a 6 mm right inferior parathyroid mass indicative of a parathyroid adenoma. Initiation of Cinacalcet therapy resulted in a prompt decline in serum calcium levels within 48 hours. The patient was planned for surgical intervention involving parathyroidectomy and bilateral nephrolithotomy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis case highlights the importance of comprehensive metabolic evaluation for patients presenting with bilateral staghorn calculi, emphasizes the need for a timely and tailored approach to urological and endocrinological management.\u003c/p\u003e","manuscriptTitle":"Bilateral Staghorn Calculi and Urosepsis as Uncommon Presentations of Primary Hyperparathyroidism","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-13 21:08:35","doi":"10.21203/rs.3.rs-4499623/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e584e659-587a-432e-90b8-888988fb4182","owner":[],"postedDate":"June 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T10:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-13 21:08:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4499623","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4499623","identity":"rs-4499623","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}