Intrathyroidal parathyroid adenomas are rare ectopic lesions that can be difficult to localize, as they often mimic benign thyroid nodules and may produce discordant anatomical and functional imaging findings. We report a 57-year-old woman with recurrent nephrolithiasis and persistent hypercalcemia due to primary hyperparathyroidism. Neck ultrasound demonstrated multiple thyroid nodules, while Tc-99m sestamibi SPECT/CT localized a focus of activity at the inferior aspect of the right thyroid lobe. Subsequent ^18F-fluorocholine PET/CT confirmed a right inferior intrathyroidal parathyroid adenoma. Intra-operatively, near-infrared autofluorescence using the PTeye system confirmed intrathyroidal parathyroid tissue, enabling targeted enucleation without thyroid tissue sacrifice. Intra-operative parathyroid hormone declined by more than 80% following excision, with postoperative normalization of serum calcium. Histopathology confirmed a parathyroid adenoma. This case highlights the value of combining advanced functional imaging with near-infrared autofluorescence to achieve accurate localization and thyroid-sparing surgery in intrathyroidal parathyroid adenomas.
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