1 Introduction

The primary hyperparathyroidism (PHPT) is, after the thyroid diseases, the most common endocrine disorder in adults especially in women. Its incidence increased in the 90s with a current stabilization at 20.8 / 100.000 (Melton., 2002). The asymptomatic forms detected by a routine calcium dosage account for 80% of the cases (Bilezikian JP., and Potts JT Jr., 2002). Some patients have a PHPT with renal consequences but they are normocalcaemic (Dutta P. K., and al., 2015). The coralliform lithiasis represents the most common clinical manifestation; about 3 to 5% of lithiasic patients have a PHPT. In Patients with persistent urinary hypercalcemia, the PHPT is more common and reached to 10% of the cases (Clark and Duh., 1989). The coralliform lithiasis is a rare urological manifestation of the PHPT and requires a multidisciplinary management.

2 Case reports

We report the case of a 53-year-old woman with a heavy urological history, a right ureteral lithiasis (15mm) treated in March 2013 through three sessions of extracorporeal lithotripsy. The patient was readmitted in April 2013 for a pelvic ureteral calculi treated with semirigid ureteroscopy fragmentation with laser. In February 2014, an obstructive left lumbar ureteral calculi (12mm) was diagnosed and treated again with a semirigid ureteroscopy with laser. The morphoconstitutional analysis of the lithiasis by infrared spectrophotometry showed an oxalo-phosphate mixed nature. In September 2015, our patient consulted for a repeated renal colic associated with fatigue and digestive disorders infections (pain and vomiting).A CT urography showed a recurrent left coralliform lithiasis (40mm, density =758 Hounsfield unit) in the pyelic region with middle and lower calices extension (Figure 1). The patient was treated with the third generation cephalosporin and aminoglycosides after a urinary antibiogram. After the negativation of urinary antibiogram, a percutaneous nephrolithotomy (NCCP) was performed with a double surgical approach of the middle and the lower calices in two stages (Figure 2).The morphoconstitutional results of the calculi showed a calcium oxalate structure (Figure 3).

The analysis by the infrared spectrophotometry showed:

-surface: Whewellite (C1)> Weddellite (C2)

-section and central mass: Whewellite (C1)> Weddellite (C2) and trace of carboapatite

-conclusion: oxalo structure and calcium-dependent lithiasis

As part of the aetiological investigation, hypercalcemia to 119 mg/l (88 -101), with hypophosphatemia to 14mg/l (27 -45), PTH=508.7pg/ml (15 -65), so the diagnosis of the PHPT was established. The ultrasound cervical scan showed a right heterogeneous hypoechoic parathyroid mass measuring 46x34 mm in contact with the thyroid gland. The parathyroid sestamibi scintigraphy confirmed an isolated enlarged lower right parathyroid gland measuring 5cm. A cervical MRI did not reveal any extension to the surrounding vascular structures. However, there was an extension to the upper mediastinum in relation to the carotid artery. A conventional cervicotomy was performed for the removal of the parathyroid adenoma which measured 5 x 2.5cm with an ipsilateral thyroid lobectomy. The postoperative course was uneventful. A month after the cervicotomy, the patient was asymptomatic and the laboratory tests became normal (calcemia=95mg/ml and PTH=39pg/ml).

3 Discussion

The first parathyroidectomy was performed by Vienna Mandle in 1925. The PHPT is one of the main causes of hypercalcemia in non-hospitalized patients and its prevalence is 0.5% to 16.7% (Charopoulas et al., 2006). In the series of Clark and al, the majority of the patients with a PHPT were symptomatic with bone and muscle pain, polydipsia, polyuria, asthenia, anorexia, constipation, pruritus and other complications such as urinary stones in 20%, osteopenia, hypertension and heart disease (Clark and Duh., 1989). The diagnosis of PHPT is confirmed by the association of hypercalcemia, hypophosphatemia and inadequate high PTH in the absence of hypocalciuria. The topographic diagnosis uses the ultrasound technics, imaging by nuclear magnetic resonance, but can only rely on irradiating examinations such as sestamibi scintigraphy (Butler .,and al., 2000). In our case, the parathyroid adenoma was easily detected on scan because of its large size. The radical treatment is an effective way to establish normocalcemia. In 10-15%, the hypercalciuria may persist despite the treatment which reflects an underlying idiopathic hypercalciuria that must be systematically tested in the lithiasic patients away from the parathyroidectomy (Van Heerden and Grant., 1991). Currently, the surgical treatment of coralliform nephrolithiasis with the bivalve nephrotomy is abandoned at the cost of PCNL monotherapy or in combination with extracorporeal lithotripsy or flexible ureteroscopy using several sources of fragmentation, laser or ultrasonic waves. This innovative technic showed satisfactory results in terms of stone-free rate (Saussinea., and  Lechevallierb., 2008). The lithiasic metabolic balance is a real etiological investigation to determine the nature and the origin of the calculi and many authors insisted for it in case of recurrent or bilateral episodes (Simon., and al 2015). The initial tests are based on the calculi morphoconstitutional study recovered with a standard blood and urine laboratory tests (Table 1). In case of multiple stones, bilateral or recurrent, nephrocalcinosis, in children, a solitary kidney, renal failure, a second line exploration in a specialized environment is mandatory, (Table 2), (Traxerb O., and al., 2008).

4 Conclusion

The urolithiasis is a common complication of the PHPT which is manifested by the nephrocalcinosis or the nephrolithiasis and more rarely a coralliform lithiasis. The treatment of the urolithiasis has been revolutionized by the PCNL as minimally invasive approach. The metabolic balance is essential to label any PHPT.

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