eMedicine Specialties > Radiology > Musculoskeletal

Hyperparathyroidism, Primary: Multimedia

Author: Bonnie Freitas, MD, Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
Coauthor(s): Alex Freitas, MD, Assistant Professor, UCLA Department of Radiology, Assistant Chief of Musculoskeletal Radiology, Renaissance Imaging Medical Associates
Contributor Information and Disclosures

Updated: Jan 24, 2008

Multimedia

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Media file 1: Radiograph of the proximal tibia and fibula. Diffuse demineralization attributed to trabecular resorption is the most common plain radiographic sign of primary hyperparathyroidism.

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Radiograph of the proximal tibia and fibula. Diffuse demineralization attributed to trabecular resorption is the most common plain radiographic sign of primary hyperparathyroidism.

(Enlarge Image)

Media file 2: Bilateral anteroposterior (AP) radiographic views of the hands in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism. These images show subperiosteal bone resorption along the radial aspects of the middle phalanges.

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Bilateral anteroposterior (AP) radiographic views of the hands in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism. These images show subperiosteal bone resorption along the radial aspects of the middle phalanges.

(Enlarge Image)

Media file 3: Anteroposterior radiographic view of the right hand in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism (same patient as in Image 2). This image shows subperiosteal bone resorption along the radial aspects of the middle phalanges (arrows).

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Anteroposterior radiographic view of the right hand in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism (same patient as in Image 2). This image shows subperiosteal bone resorption along the radial aspects of the middle phalanges (arrows).

(Enlarge Image)

Media file 4: Radiograph of the middle phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (white arrows). Also, note the subperiosteal and intracortical resorption of the middle phalanges (black arrows).

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Radiograph of the middle phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (white arrows). Also, note the subperiosteal and intracortical resorption of the middle phalanges (black arrows).

(Enlarge Image)

Media file 5: Anteroposterior radiographic view of the left shoulder in external rotation in a patient with primary hyperparathyroidism. This image shows the healing stage of marked subperiosteal resorption (arrow) of the medial aspect of the proximal humerus.

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Anteroposterior radiographic view of the left shoulder in external rotation in a patient with primary hyperparathyroidism. This image shows the healing stage of marked subperiosteal resorption (arrow) of the medial aspect of the proximal humerus.

(Enlarge Image)

Media file 6: Radiograph of the proximal humerus in a patient with primary hyperparathyroidism (same patient as in Image 5). This image shows the healing stage of marked subperiosteal resorption of the medial aspect of the proximal humerus. A subsequent fracture through the surgical neck of the humerus is also depicted.

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Radiograph of the proximal humerus in a patient with primary hyperparathyroidism (same patient as in Image 5). This image shows the healing stage of marked subperiosteal resorption of the medial aspect of the proximal humerus. A subsequent fracture through the surgical neck of the humerus is also depicted.

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Media file 7: Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image depicts subperiosteal distal clavicular resorption (arrows).

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Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image depicts subperiosteal distal clavicular resorption (arrows).

(Enlarge Image)

Media file 8: Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image demonstrates distal clavicular resorption.

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Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image demonstrates distal clavicular resorption.

(Enlarge Image)

Media file 9: Anteroposterior radiographic view of the top of the calvarium in a patient with primary hyperparathyroidism. This image shows trabecular bone resorption that has resulted in the salt-and-pepper appearance of the calvarium.

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Anteroposterior radiographic view of the top of the calvarium in a patient with primary hyperparathyroidism. This image shows trabecular bone resorption that has resulted in the salt-and-pepper appearance of the calvarium.

(Enlarge Image)

Media file 10: Radiograph of the distal femur in a patient with primary hyperparathyroidism. This image shows scalloped defects along the inner margin of the cortex, which denote endosteal resorption.

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Radiograph of the distal femur in a patient with primary hyperparathyroidism. This image shows scalloped defects along the inner margin of the cortex, which denote endosteal resorption.

(Enlarge Image)

Media file 11: Radiograph of the femur in primary hyperparathyroidism (same patient as in Image 10). This image shows scalloped defects along the inner margin of the femoral cortex (arrows), which denote endosteal resorption.

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Radiograph of the femur in primary hyperparathyroidism (same patient as in Image 10). This image shows scalloped defects along the inner margin of the femoral cortex (arrows), which denote endosteal resorption.

(Enlarge Image)

Media file 12: Anteroposterior radiographic view of the clavicles. This image shows symmetric subchondral bone resorption of the acromioclavicular joints. Distal clavicular resorption can be subperiosteal or subchondral, but this finding is not specific for primary hyperparathyroidism.

[ CLOSE WINDOW ]

Anteroposterior radiographic view of the clavicles. This image shows symmetric subchondral bone resorption of the acromioclavicular joints. Distal clavicular resorption can be subperiosteal or subchondral, but this finding is not specific for primary hyperparathyroidism.

(Enlarge Image)

Media file 13: Radiograph of the humerus in a patient with primary hyperparathyroidism. This image depicts a brown tumor. Note the osseous expansion and lucency of the proximal humerus. Brown tumors can have varied appearances.

[ CLOSE WINDOW ]

Radiograph of the humerus in a patient with primary hyperparathyroidism. This image depicts a brown tumor. Note the osseous expansion and lucency of the proximal humerus. Brown tumors can have varied appearances.

(Enlarge Image)

Media file 14: Radiograph of the mid femoral diaphysis in a patient with primary hyperparathyroidism. This image depicts brown tumors. Note the eccentric (arrowheads) and central positions (arrow) of the lesions.

[ CLOSE WINDOW ]

Radiograph of the mid femoral diaphysis in a patient with primary hyperparathyroidism. This image depicts brown tumors. Note the eccentric (arrowheads) and central positions (arrow) of the lesions.

(Enlarge Image)

Media file 15: Radiograph of the pelvis in a patient with primary hyperparathyroidism. Note the presence of brown tumors in the pelvis.

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Radiograph of the pelvis in a patient with primary hyperparathyroidism. Note the presence of brown tumors in the pelvis.

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Media file 16: Radiograph of brown tumors of the pelvis in a patient with primary hyperparathyroidism (same patient as in Image 15).

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Radiograph of brown tumors of the pelvis in a patient with primary hyperparathyroidism (same patient as in Image 15).

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Media file 17: Sonogram of the kidney in a patient with primary hyperparathyroidism. This image shows medullary nephrocalcinosis.

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Sonogram of the kidney in a patient with primary hyperparathyroidism. This image shows medullary nephrocalcinosis.

Technetium-99m sestamibi (<SUP><FONT size=-1>99m<...

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Media file 18: Technetium-99m sestamibi (^99mTc MIBI) images in a patient with primary hyperparathyroidism. The initial (A) and 3.5-hour delayed (B) images demonstrate a 6-cm parathyroid adenoma (arrows).

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Technetium-99m sestamibi (^99mTc MIBI) images in a patient with primary hyperparathyroidism. The initial (A) and 3.5-hour delayed (B) images demonstrate a 6-cm parathyroid adenoma (arrows).

Technetium-99m sestamibi scan (<sup>99m</sup>Tc M...

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Media file 19: Technetium-99m sestamibi scan (^99mTc MIBI) in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images demonstrate persistent abnormal activity of the inferior right parathyroid gland that is consistent with an adenoma.

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Technetium-99m sestamibi scan (^99mTc MIBI) in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images demonstrate persistent abnormal activity of the inferior right parathyroid gland that is consistent with an adenoma.

Sagittal (<i>left image</i>) and coronal (<i>righ...

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Media file 20: Sagittal (left image) and coronal (right image) T1-weighted magnetic resonance images of the brain in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images show a pituitary macroadenoma (arrows).

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Sagittal (left image) and coronal (right image) T1-weighted magnetic resonance images of the brain in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images show a pituitary macroadenoma (arrows).

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Media file 21: Computed tomography (CT) scan of the pancreas in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and a gastrinoma (same patient in Images 19-22). This image shows a pancreatic head mass (large white arrow), as well as a low-attenuating lesion in the liver (small black arrowhead) that indicates metastases. Note the calcifications of the right renal medullary pyramids (medullary nephrocalcinosis; black arrows) in this nonenhanced CT scan.

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Computed tomography (CT) scan of the pancreas in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and a gastrinoma (same patient in Images 19-22). This image shows a pancreatic head mass (large white arrow), as well as a low-attenuating lesion in the liver (small black arrowhead) that indicates metastases. Note the calcifications of the right renal medullary pyramids (medullary nephrocalcinosis; black arrows) in this nonenhanced CT scan.

Indium-111 (<sup>111</sup>In) octreotide scan in ...

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Media file 22: Indium-111 (¹¹¹In) octreotide scan in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These nuclear images demonstrate abnormal activity in the pituitary macroadenoma (curved arrow), parathyroid adenoma (straight arrow), and gastrinoma metastases throughout the abdomen (arrowheads).

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Indium-111 (¹¹¹In) octreotide scan in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These nuclear images demonstrate abnormal activity in the pituitary macroadenoma (curved arrow), parathyroid adenoma (straight arrow), and gastrinoma metastases throughout the abdomen (arrowheads).

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Media file 23: Radiograph of the phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (arrows).

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Radiograph of the phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (arrows).

More on Hyperparathyroidism, Primary

Overview: Hyperparathyroidism, Primary

Imaging: Hyperparathyroidism, Primary

Follow-up: Hyperparathyroidism, Primary

Multimedia: Hyperparathyroidism, Primary

References

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References

Albright F, Aub JC, Bauer W. Hyperparathyroidism, a common and polymorphic condition as illustrated by seventeen proved cases from one clinic. JAMA. 1934;102:1276-87.
Albright F, Reifenstein EC Jr. Clinical hyperparathyroidism. In: Albright F, Reifenstein EC Jr, eds. The Parathyroid Glands and Metabolic Bone Disease: Selected Studies. Baltimore, Md: Williams & Wilkins; 1948:46-134.
Mihai R, Wass JA, Sadler GP. Asymptomatic hyperparathyroidism--need for multicentre studies. Clin Endocrinol (Oxf). Feb 2008;68(2):155-64. [Medline].
Silverberg SJ. Natural history of primary hyperparathyroidism. Endocrinol Metab Clin North Am. Sep 2000;29(3):451-64. [Medline].
Marx SJ. Hyperparathyroid and hypoparathyroid disorders. N Engl J Med. Dec 21 2000;343(25):1863-75. [Medline].
Bringhurst FR, Demay MB, Kronenberg HM. Hormones and disorders of mineral metabolism. In: Williams RH, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology. 9^th ed. Orlando, Fla: Harcourt Brace & Co; 1998:1172-80.
Lenchik L, Sartoris DJ. Orthopedic aspects of metabolic bone disease. Orthop Clin North Am. Jan 1998;29(1):103-34. [Medline].
Cotran RS, Kumar V, Robbins SL. Robbins Pathologic Basis of Disease. 5^th ed. Philadelphia, Pa: WB Saunders Co; 1994:1144-6.
Mankin HJ. Metabolic bone disease. J Bone Joint Surg. 1994;76-A:760-88. [Full Text].
Hayes CW, Conway WF. Hyperparathyroidism. Radiol Clin North Am. Jan 1991;29(1):85-96. [Medline].
Resnick D, Niwayama G. Parathyroid disorders and renal osteodystrophy. In: Resnick D, Niwayama G, eds. Diagnosis of Bone and Joint Disorders. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1988:2219-49.
Genant HK. Quantitative bone mineral analysis. In: Resnick D, Niwayama G, eds. Diagnosis of Bone and Joint Disorders. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1988:2006-17.
Gleason DC, Potchen EJ. The diagnosis of hyperparathyroidism. Radiol Clin North Am. Aug 1967;5(2):277-87. [Medline].
Inoue Y, Kaji H, Hisa I, et al. Vitamin D status affects osteopenia in postmenopausal patients with primary hyperparathyroidism. Endocr J. Jan 10 2008;epub ahead of print. [Medline]. [Full Text].
Moosgaard B, Christensen SE, Vestergaard P, et al. Vitamin D metabolites and skeletal consequences in primary hyperparathyroidism. Clin Endocrinol (Oxf). Jan 8 2008;epub ahead of print. [Medline].
Fogelman I, Cook GJ. Scintigraphy in metabolic bone disease. In: Favus MJ, Goldring SR, Christakos S, eds. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4^th ed. Hagerstown, Md: Lippincott Williams & Wilkins; 1999:150-2.
Jergas MD, Genant HK. Radiology of osteoporosis. In: Favus MJ, Goldring SR, Christakos S, eds. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4^th ed. Hagerstown, Md: Lippincott Williams & Wilkins; 1999:160-5.
Mayo-Smith W, Rosenthal DI. Radiographic appearance of osteopenia. Radiol Clin North Am. Jan 1991;29(1):37-47. [Medline].
Reynolds WA, Karo JJ. Radiologic diagnosis of metabolic bone disease. Orthop Clin North Am. Nov 1972;3(3):521-43. [Medline].
Pugh DG. Subperiosteal resorption of bone; a roentgenologic manifestation of primary hyperparathyroidism and renal osteodystrophy. Am J Roentgenol Radium Ther Nucl Med. Oct 1951;66(4):577-86. [Medline].
Rodgers SE, Lew JI, Solórzano CC. Primary hyperparathyroidism. Curr Opin Oncol. Jan 2008;20(1):52-8. [Medline].
Erbil Y, Kapran Y, Issever H, et al. The positive effect of adenoma weight and oxyphil cell content on preoperative localization with 99mTc-sestamibi scanning for primary hyperparathyroidism. Am J Surg. Jan 2008;195(1):34-9. [Medline].
Gupta Y, Ahmed R, Happerfield L, et al. P-glycoprotein expression is associated with sestamibi washout in primary hyperparathyroidism. Br J Surg. Dec 2007;94(12):1491-5. [Medline].
Carlier T, Oudoux A, Mirallié E, et al. (99m)Tc-MIBI pinhole SPECT in primary hyperparathyroidism: comparison with conventional SPECT, planar scintigraphy and ultrasonography. Eur J Nucl Med Mol Imaging. Oct 25 2007;epub ahead of print. [Medline].
Siegel A, Mancuso M, Seltzer M. The spectrum of positive scan patterns in parathyroid scintigraphy. Clin Nucl Med. Oct 2007;32(10):770-4. [Medline].
Prasannan S, Davies G, Bochner M, Kollias J, Malycha P. Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi. ANZ J Surg. Sep 2007;77(9):774-7. [Medline].
Gotway MB, Reddy GP, Webb WR, et al. Comparison between MR imaging and 99mTc MIBI scintigraphy in the evaluation of recurrent of persistent hyperparathyroidism. Radiology. Mar 2001;218(3):783-90. [Medline]. [Full Text].
Gritzmann N, Koischwitz D, Rettenbacher T. Sonography of the thyroid and parathyroid glands. Radiol Clin North Am. Sep 2000;38(5):1131-45, xii. [Medline].
Weber AL, Randolph G, Aksoy FG. The thyroid and parathyroid glands. CT and MR imaging and correlation with pathology and clinical findings. Radiol Clin North Am. Sep 2000;38(5):1105-29. [Medline].
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Eigelberger MS, Clark OH. Surgical approaches to primary hyperparathyroidism. Endocrinol Metab Clin North Am. Sep 2000;29(3):479-502. [Medline].
Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16^th ed. Philadelphia, Pa: WB Saunders Co; 2001:632-7.

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Keywords

von Recklinghausen's disease of bone, von Recklinghausen disease of bone, generalized osteitis fibrosa cystica, PTH, parathyroid glands, multiple endocrine neoplasia syndrome type 1, MEN 1 / MEN-1, brown tumor

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Contributor Information and Disclosures

Author

Bonnie Freitas, MD, Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
Bonnie Freitas, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Alex Freitas, MD, Assistant Professor, UCLA Department of Radiology, Assistant Chief of Musculoskeletal Radiology, Renaissance Imaging Medical Associates
Alex Freitas, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, Radiological Society of North America, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Medical Editor

Leon Lenchik, MD, Director, Densitometry Minifellowship, Assistant Professor, Department of Radiology, Wake Forest University Medical Center
Leon Lenchik, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Wilfred CG Peh, MD, MBBS, FRCP(Glasg), FRCP(Edin), FRCR, MHSM, Clinical Professor, Faculty of Medicine, National University of Singapore; Senior Consultant Radiologist, Programme Office, Singapore Health Services
Wilfred CG Peh, MD, MBBS, FRCP(Glasg), FRCP(Edin), FRCR, MHSM is a member of the following medical societies: American Roentgen Ray Society, British Institute of Radiology, International Skeletal Society, Radiological Society of North America, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

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eMedicine Specialties > Radiology > Musculoskeletal

Hyperparathyroidism, Primary: Multimedia

Multimedia

Radiograph of the proximal tibia and fibula. Diffuse demineralization attributed to trabecular resorption is the most common plain radiographic sign of primary hyperparathyroidism.

Bilateral anteroposterior (AP) radiographic views of the hands in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism. These images show subperiosteal bone resorption along the radial aspects of the middle phalanges.

Anteroposterior radiographic view of the right hand in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism (same patient as in Image 2). This image shows subperiosteal bone resorption along the radial aspects of the middle phalanges (arrows).

Radiograph of the middle phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (white arrows). Also, note the subperiosteal and intracortical resorption of the middle phalanges (black arrows).

Anteroposterior radiographic view of the left shoulder in external rotation in a patient with primary hyperparathyroidism. This image shows the healing stage of marked subperiosteal resorption (arrow) of the medial aspect of the proximal humerus.

Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image depicts subperiosteal distal clavicular resorption (arrows).

Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image demonstrates distal clavicular resorption.

Anteroposterior radiographic view of the top of the calvarium in a patient with primary hyperparathyroidism. This image shows trabecular bone resorption that has resulted in the salt-and-pepper appearance of the calvarium.

Radiograph of the distal femur in a patient with primary hyperparathyroidism. This image shows scalloped defects along the inner margin of the cortex, which denote endosteal resorption.

Radiograph of the femur in primary hyperparathyroidism (same patient as in Image 10). This image shows scalloped defects along the inner margin of the femoral cortex (arrows), which denote endosteal resorption.

Anteroposterior radiographic view of the clavicles. This image shows symmetric subchondral bone resorption of the acromioclavicular joints. Distal clavicular resorption can be subperiosteal or subchondral, but this finding is not specific for primary hyperparathyroidism.

Radiograph of the humerus in a patient with primary hyperparathyroidism. This image depicts a brown tumor. Note the osseous expansion and lucency of the proximal humerus. Brown tumors can have varied appearances.

Radiograph of the mid femoral diaphysis in a patient with primary hyperparathyroidism. This image depicts brown tumors. Note the eccentric (arrowheads) and central positions (arrow) of the lesions.

Radiograph of the pelvis in a patient with primary hyperparathyroidism. Note the presence of brown tumors in the pelvis.

Radiograph of brown tumors of the pelvis in a patient with primary hyperparathyroidism (same patient as in Image 15).

Sonogram of the kidney in a patient with primary hyperparathyroidism. This image shows medullary nephrocalcinosis.

Technetium-99m sestamibi (99mTc MIBI) images in a patient with primary hyperparathyroidism. The initial (A) and 3.5-hour delayed (B) images demonstrate a 6-cm parathyroid adenoma (arrows).

Technetium-99m sestamibi scan (99mTc MIBI) in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images demonstrate persistent abnormal activity of the inferior right parathyroid gland that is consistent with an adenoma.

Sagittal (left image) and coronal (right image) T1-weighted magnetic resonance images of the brain in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images show a pituitary macroadenoma (arrows).

Radiograph of the phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (arrows).

More on Hyperparathyroidism, Primary

References

Further Reading

Keywords

Contributor Information and Disclosures

Author

Coauthor(s)

Medical Editor

Pharmacy Editor

Managing Editor

CME Editor

Chief Editor

Technetium-99m sestamibi (^99mTc MIBI) images in a patient with primary hyperparathyroidism. The initial (A) and 3.5-hour delayed (B) images demonstrate a 6-cm parathyroid adenoma (arrows).

Technetium-99m sestamibi scan (^99mTc MIBI) in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) (same patient in Images 19-22). These images demonstrate persistent abnormal activity of the inferior right parathyroid gland that is consistent with an adenoma.