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We present a 45 year old female who was initially seen by Rheumatologist with long standing knee pain affecting her mobility. She was found to be severely hypercalcaemic and exhibited features suggestive of parathyroid carcinoma (palpable neck mass, extremely high parathyroid hormone, high alkaline phosphatase, concomitant presence of renal disease and skeletal involvement). Hence she was referred for parathyroidectomy. Postoperatively she developed profound hypocalcaemia with markedly raised serum alkaline phosphatase, requiring intensive intravenous calcium and oral vitamin D supplements, consistent with the development of hungry bone syndrome (HBS). HBS is a complication of parathyroid surgery where the correction of primary hyperparathyroidism is associated with rapid bone remineralisation, causing severe and prolonged hypocalcaemia. HBS is relatively rare but has to be considered in the differential diagnosis of postoperative hypocalcaemia particularly in severe cases. In the current report, we discuss pathogenesis, clinical course and management of HBS.

Objective: To compare the peak GH and cortisol responses to the simplified and standard i.m. glucagon stimulation test (IMGST) in order to determine whether the use of a simplified form of this test results in a loss of diagnostic utility. PATIENT AND DESIGN: A retrospective study of 35 consecutive patients with pituitary disease who underwent a standard IMGST to measure GH (n = 34) or cortisol (n = 21) reserve at the programmed investigation unit of the Northern General Hospital, Sheffield., Measurements: Cortisol, glucose and GH levels were measured at baseline and 30, 60, 90, 120, 150, 180, 210 and 240 min during the standard IMGST. We used the hormone levels at baseline, 150 and 180 min for the simplified IMGST and compared the cortisol and GH responses achieved., Results: The median (range) peak GH and cortisol responses to simplified and standard IMGST were comparable 4.2 (0.5-47.5) vs 5.4 (0.5-47.5) mU/l (P = 0.75) and 635 (306-1669) vs 647 (306-1669) nmol/l (P = 0.801), respectively. Using the standard 'cut-off' points to assess GH (9 mU/l) or cortisol deficiency (580 nmol/l) there was no significant loss of diagnostic utility (P = 0.98 and P = 1.00, respectively)., Conclusions: The simplified and standard IMGST have a similar diagnostic utility. The simplified IMGST could replace the standard IMGST as a screening test for GH and cortisol reserve in pituitary disease. The insulin-induced hypoglycaemia stress test can be reserved for cases in which a second assessment of pituitary reserve is clinically indicated or because of an indeterminate biochemical result.