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Management of hypocalcemia in a person with hungry bone syndrome post parathyroidectomy due to parathyroid carcinoma: a case report

  • Dananti Kusumawindani ,
  • Sony Wibisono Mudjanarko ,
  • Hermina Novida ,


Introduction: Hungry Bone Syndrome (HBS) refers to a condition in the form of prolonged and severe hypocalcemia accompanied by hypophosphatemia and hypomagnesemia that occurs after parathyroidectomy. The sudden cessation of PTH production leads to increased bone re-mineralization and a rapid shift of calcium from circulation to bone. This case report aims to present our management of hypocalcemia in a person with HBS after he underwent parathyroidectomy surgery due to parathyroid carcinoma.

Case Presentation: Mr. S, 46 years old, had a total thyroidectomy and a total parathyroidectomy on April 30th, 2019, due to parathyroid carcinoma, which the patient previously had. The patient was planned for surgery because of pathological fractures in the patient's hands and feet, which were complications of parathyroid carcinoma. The laboratory examination on the first postoperative day, May 1st, 2019, obtained a total calcium of 8.2 mg/dL. On May 5th, 2019 (day 5), total calcium decreased to 6.1 mg/dL. On May 10th, 2019 (day 10), hypophosphatemia was also found with a value of 2.1 mg/dL and hypomagnesemia of 1.2 mg/dL. When experiencing complaints, the patient's calcium was monitored regularly, low calcium was found, and symptoms of hypocalcemia were also found, so this patient was given drip calcium gluconate 1000 mg every 8 hours in 100 ml normal saline. Calcium checks are carried out every 24 hours; calcium is still low for over 3 days. In addition, he was given calcitriol 2x0.25 mcg titrated up to 2x0.5 mcg, drip 40% MgSO4 in 500 salines in 24 hours, and 4x200 oral phosphate. During the treatment, the patient's calcium reached 8.2 mg/dL with albumin 3.3 g/dL with a calcium ion count of 8.4 mg/dL after 17 days of treatment.

Conclusion: HBS was found due to total parathyroidectomy as the main therapy for parathyroid carcinoma. Close calcium monitoring and early administration of postoperative calcium are needed to avoid complications from hypocalcemia. Avoiding HBS can reduce the number of days in the hospital, thereby saving costs and improving the patient's quality of life.


  1. Givi, B; Shah J. Parathyroid Carcinoma Review. 2013;22(6):498–507.
  2. Hundahl SA. Two hundred eighty-six cases of parathyroid carcinoma treated in the U.S. between 1985-1995: a National Cancer Data Base Report. The American College of Surgeons Commission on Cancer and the American Cancer Society. Cancer. 1999;86(0008-543X (Print)):538–44.
  3. Ohe MN, Santos RO, Hojaij F, Neves MC, Kunii IS, Orlandi D, et al. Parathyroid carcinoma and hungry bone syndrome. Arq Bras Endocrinol Metabol. 2013;57(1):79–86.
  4. Wei CH, Harari A. Parathyroid carcinoma: Update and guidelines for management. Curr Treat Options Oncol. 2012;13(1):11–23.
  5. Setiawan FD, Novida H. Recurrent seizures as manifestation of hypoparathyroidism-related hypocalcemia in a patient with post-subtotal thyroidectomy. Bali Med J. 2022;11(3 SE-CASE REPORT):1780–3. Available from:
  6. Pradeep P V., Agarwal A, Baxi M, Agarwal G, Gupta SK, Mishra SK. Safety and efficacy of surgical management of hyperthyroidism: 15-Year experience from a tertiary care center in a developing country. World J Surg. 2007;31(2):306–12.
  7. Witteveen JE, van Thiel S, Romijn JA, Hamdy NA. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol. 2013;168(3):45–53.
  8. Agarwal G, Mishra SK, Kar DK, Singh AK, Arya V, Gupta SK, et al. Recovery pattern of patients with osteitis fibrosa cystica in primary hyperparathyroidism after successful parathyroidectomy. Surgery. 2002;132(6):1075–85.
  9. Pradeep P V., Jayashree B, Mishra A, Mishra SK. Systematic Review of Primary Hyperparathyroidism in India: The Past, Present, and the Future Trends. Int J Endocrinol. 2011;2011:1–7.
  10. Cheng SP, Liu CL, Chen HH, Lee JJ, Liu TP, Yang TL. Prolonged hospital stay after parathyroidectomy for secondary hyperparathyroidism. World J Surg. 2009;33(1):72–9.
  11. J.E. H. Pocket Companion to Textbook of Medical Physiology. Elsevier Inc. 2006.
  12. Adyanita VA, Widajanti N, Wibisono S. Comparison of the 25 ( OH ) D Levels Between Sarcopenia and Frailty in Elder Women : A Cross-Sectional Observation Analytic Study in Elderly Community in Surabaya. 2020;11(4):359–64.
  13. Stack BC, Bimston DN, Bodenner DL, Brett EM, Dralle H, Orloff LA, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: Postoperative Hypoparathyroidism - Definitions and Management. Endocr Pract. 2015;21(6):674–85.
  14. Bollerslev J, Rejnmark L, Marcocci C, Shoback DM, Sitges-Serra A, van Biesen W, et al. European Society of Endocrinology Clinical Guideline: Treatment of chronic hypoparathyroidism in adults. Eur J Endocrinol. 2015;173(2):G1–20.
  15. Ajmi S, Sfar R, Trimeche S, Ben Ali K, Nouira M. Scintigraphic findings in hungry bone syndrome following parathyroidectomy. Rev Esp Med Nucl. 2010;29(2):81–3.
  16. Anwar F, Abraham J, Nakshabandi A, Lee E. Treatment of hypocalcemia in hungry bone syndrome: A case report. Int J Surg Case Rep. 2018;51(April 2017):335–9.
  17. Rathi MS, Aljan R, Orme SM. A case of parathyroid carcinoma with severe hungry bone syndrome and review of literature. Exp Clin Endocrinol Diabetes. 2008;116(8):487–90.
  18. de França TCPT, Griz L, Pinho J, Diniz ET, de Andrade LD, Lucena CS, et al. Bisphosphonates can reduce bone hunger after parathyroidectomy in patients with primary hyperparathyroidism and osteitis fibrosa cystica. Rev Bras Reumatol. 2011;51(2):124–30.
  19. Bilezikian JP, Khan A, Potts JT, Brandi ML, Clarke BL, Shoback D, et al. Hypoparathyroidism in the adult: Epidemiology, diagnosis, pathophysiology, target-organ involvement, treatment, and challenges for future research. J Bone Miner Res. 2011;26(10):2317–37.
  20. Mallick UK, Mazzaferri EL, Harmer C, Kendall-Taylor P. Practical management of thyroid cancer: A multidisciplinary approach. Pract Manag Thyroid Cancer A Multidiscip Approach. 2018;1–385.
  21. Hansen KE, Jones AN, Lindstrom MJ, Davis LA, Ziegler TE, Penniston KL, et al. Do proton pump inhibitors decrease calcium absorption? J Bone Miner Res. 2010;25(12):2510–9.
  22. Leiker AJ, Yen TWF, Eastwood DC, Doffek KM, Szabo A, Evans DB, et al. Factors that influence parathyroid hormone half-life: Determining if new intraoperative criteria are needed. JAMA Surg. 2013;148(7):602–6.
  23. Cusano NE, Rubin MR, McMahon DJ, Irani D, Tulley A, Sliney J, et al. The effect of PTH(1-84) on quality of life in hypoparathyroidism. J Clin Endocrinol Metab. 2013;98(6):2356–61.
  24. Adriana DN, Pranoto A. The role of Teriparatide in post-thyroidectomy permanent hypoparathyroidism : A case report. 2022;100(1):135–41.

How to Cite

Kusumawindani, D., Mudjanarko, S. W., & Novida, H. (2023). Management of hypocalcemia in a person with hungry bone syndrome post parathyroidectomy due to parathyroid carcinoma: a case report. Bali Medical Journal, 12(1), 991–995.




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Dananti Kusumawindani
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Sony Wibisono Mudjanarko
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Hermina Novida
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