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Hypoparathyroidism and thoracic duct injury are potential complications following total thyroidectomy with extensive lymph node dissection. This case suggested Selleckchem Galunisertib that having both conditions may complicate treatment of hypoparathyroid-induced hypocalcemia by way of losses of calcium and vitamin D in the chyle leak. Learning points This report highlights chyle leak as an uncommon cause of prolonged hypocalcemia in patients who have undergone extensive neck surgery. Chyle has an electrolyte concentration similar to that of plasma. Medical treatment options for a chyle leak include fat-free oral diet or parenteral nutrition without oral intake, pharmacological treatment (primarily octreotide). Background Patients who undergo total thyroidectomy and/or extensive neck dissection are at a higher risk for hypocalcemia. One common cause is acute hypoparathyroidism because of devascularization and/or inadvertent removal of parathyroid glands during neck dissection (1). Although not a well-known cause of hypocalcemia, injury to the thoracic duct causing a leak of chyle is a common complication of extensive neck surgery (2) (3). Chyle leakage develops as a result of injury to the lymphatic duct entering the venous system at the junction of the internal jugular and subclavian veins during or after lateral neck dissection (8). Its injury has been associated with loss of electrolytes and fat-soluble RhoC vitamins. We report a case of a patient who underwent total thyroidectomy with extensive neck dissection for medullary thyroid cancer. Surgery was complicated by hypoparathyroidism and thoracic duct injury. Post-operatively, hypocalcemia was treated with oral calcium and calcitriol; however, it abruptly worsened requiring continuous i.v. calcium infusion during a concurrent increase in the output of chyle from the injured thoracic duct. Stabilization of serum calcium concentration with transition to oral calcium and calcitriol occurred Z-VAD-FMK mw simultaneously with a decrease in the chyle output. Case presentation A 58-year-old man with multiple thyroid nodules and enlarged cervical lymph nodes was diagnosed with medullary thyroid cancer via fine needle aspiration biopsy. The patient underwent total thyroidectomy with extensive lymph node dissection that was complicated by hypoparathyroidism and thoracic duct injury. Investigation On post-operative day 1, serum ionized calcium (iCa) level was 3.9?mg/dl (4.2-5.2 reference range) and parathyroid hormone (PTH) was