Primary hyperparathyroidism

Endocrinology, Metabolism and Nutrition

Clinicals - History

Fact Explanation
Renal colic Hypersecreted parathyroid hormone acts on kidney, and reduce the excretion of calcium via urine. Increased calcium can precipitate as stones This nephrocalcinosis causing loin to groin pain. Most of them are calcium oxalate and occasionally calcium phosphate. Renal colic
Hypersecreted parathyroid hormone acts on kidney, and reduce the excretion of calcium via urine. Increased calcium can precipitate as stones This nephrocalcinosis causing loin to groin pain. Most of them are calcium oxalate and occasionally calcium phosphate.
Skeletal problems Bones are frequently affected by thgis problem. Parathyroid hormone causes bone resorption, leading to bone pain and pathological fractures and osteoporosis. Skeletal problems
Bones are frequently affected by thgis problem. Parathyroid hormone causes bone resorption, leading to bone pain and pathological fractures and osteoporosis.
Gout and pseudogout Due to chondrocalcinosis. Gout and pseudogout
Due to chondrocalcinosis.
Peptic ulcer disease Peptic ulcer disease is one of the complications of hypercalcaemia. This may be due to increased levels of gastrin and gastric acid secretion Peptic ulcer disease
Peptic ulcer disease is one of the complications of hypercalcaemia. This may be due to increased levels of gastrin and gastric acid secretion
Epigastric pain radiating to the back Pancreatitis is a known complication of hyperparathyroidism, which may be due to the blocking of the duct by stones occuring due to hypercalcaemia. Epigastric pain radiating to the back
Pancreatitis is a known complication of hyperparathyroidism, which may be due to the blocking of the duct by stones occuring due to hypercalcaemia.
Neurological problems Neurological problems are a well defined manifestation of hyperparathyroidism. There can be abnormalities in calcium transport across the cell membrane due to hypercalcaemia and hypophosphatemia. Manifestations will be proximal muscle weakness, easy fatigubility, ansomnia, depression and poor memory. Neurological problems
Neurological problems are a well defined manifestation of hyperparathyroidism. There can be abnormalities in calcium transport across the cell membrane due to hypercalcaemia and hypophosphatemia. Manifestations will be proximal muscle weakness, easy fatigubility, ansomnia, depression and poor memory.
Constipation Due to hypercalcaemia. Constipation
Due to hypercalcaemia.
Polyuria, polydypsia Due to hypercalcaemia. Polyuria, polydypsia
Due to hypercalcaemia.
Skin pruritus This is due to calcium depositions in the skin. There can be itching of the skin, which sometimes can be a chronic problem. Skin pruritus
This is due to calcium depositions in the skin. There can be itching of the skin, which sometimes can be a chronic problem.
Multiple Endocrine Neoplasia type 1 (MEN1) and MEN type 2a, Multiple Endocrine Neoplasia type 1 (MEN1) is an autosomal-dominant condition associated with parathyroid adenomas. There are parathyroids, pancreas and pituitary tumours. Multiple Endocrine Neoplasia type 2a include parathyroid hyperplasia, medullary thyroid carcinoma, pheachromocytoma and mucosal neuromas of the lips and tongue. Multiple Endocrine Neoplasia type 1 (MEN1) and MEN type 2a,
Multiple Endocrine Neoplasia type 1 (MEN1) is an autosomal-dominant condition associated with parathyroid adenomas. There are parathyroids, pancreas and pituitary tumours. Multiple Endocrine Neoplasia type 2a include parathyroid hyperplasia, medullary thyroid carcinoma, pheachromocytoma and mucosal neuromas of the lips and tongue.
Weakness, malaise, fatigue These are non specific symptoms of hyperparathyroidism. Weakness, malaise, fatigue
These are non specific symptoms of hyperparathyroidism.

Clinicals - Examination

Fact Explanation
Pallor Associated feature of hyperparathyroidism and also may be due to malignancy of parathyroid glands. There is very rare occasions where hyperparathyroidism is responsible for the pancytopenia. Pallor
Associated feature of hyperparathyroidism and also may be due to malignancy of parathyroid glands. There is very rare occasions where hyperparathyroidism is responsible for the pancytopenia.
Eye manifestations Subconjunctival,corneal and limbal deposits of calcium are seen. Eye manifestations
Subconjunctival,corneal and limbal deposits of calcium are seen.
Depressed mood One of the major manifestation of hypercalcaemia. Depressed mood
One of the major manifestation of hypercalcaemia.
Dehydration Due to hypercalcaemia they can have polyuria, polydypsia. Dehydration
Due to hypercalcaemia they can have polyuria, polydypsia.
Hypertension Hypertension is a complication of primary hyperparathyroidism. May be due to hypercalcaemia, renal impairment or associated phaeachromocytoma in MEN 2a. Hypertension
Hypertension is a complication of primary hyperparathyroidism. May be due to hypercalcaemia, renal impairment or associated phaeachromocytoma in MEN 2a.
Localized swelling Accumulation of osteoclasts, osteoblasts will appear as localized swellings. Localized swelling
Accumulation of osteoclasts, osteoblasts will appear as localized swellings.
Proximal muscle weakness,dysphasia Associated neurological manifestation of primary hyperparathyroidism. Proximal muscle weakness,dysphasia
Associated neurological manifestation of primary hyperparathyroidism.
Rare neurological manifestations Tongue atrophy, loss of vibratory sense, glove and stocking sensory loss Rare neurological manifestations
Tongue atrophy, loss of vibratory sense, glove and stocking sensory loss

Investigations - Diagnosis

Fact Explanation
Serum parathyroid hormone level This is elevated or normal Parathyroid hormone assay is the most useful test for differentiating hyperparathyroidism from malignancy and other causes of hypercalcemia. 3 Serum parathyroid hormone level
This is elevated or normal Parathyroid hormone assay is the most useful test for differentiating hyperparathyroidism from malignancy and other causes of hypercalcemia. 3
Serum calcium Almost always high. Serum calcium
Almost always high.
Serum phosphate This may be low. Serum phosphate
This may be low.
Alkaline phosphate level May be high due to bone resorption. Alkaline phosphate level
May be high due to bone resorption.
Vitamin D metabolites Serum 25-hydroxyvitamin D levels should be measured and correction should be done in a deficiency. Vitamin D metabolites
Serum 25-hydroxyvitamin D levels should be measured and correction should be done in a deficiency.
24 hour urinary calcium Increased due to hypercalcaemia. 24 hour urinary calcium
Increased due to hypercalcaemia.
Protein electrophoresis To exclude the other conditions presenting with hypercalcaemia such as multiple myeloma. Protein electrophoresis
To exclude the other conditions presenting with hypercalcaemia such as multiple myeloma.
Cervical ultrasound, computer tomography and magnetic resonance imaging of the neck This is done to demonstrate the parathyroid adenoma. This is also used to localize the adenoma prior to surgery. Cervical ultrasound, computer tomography and magnetic resonance imaging of the neck
This is done to demonstrate the parathyroid adenoma. This is also used to localize the adenoma prior to surgery.
X-ray On X-ray imaging, brown tumors will be appearing as lytic lesions. Other changes would be osteopenia, 'salt-and-pepper' appearance on skull x-ray, subperiostal bone resorption and patchy diffuse areas of osteoclerosis. X-ray
On X-ray imaging, brown tumors will be appearing as lytic lesions. Other changes would be osteopenia, 'salt-and-pepper' appearance on skull x-ray, subperiostal bone resorption and patchy diffuse areas of osteoclerosis.

Investigations - Management

Fact Explanation
Post op Calcium level an parathyroid hormone level is important in follow up after surgery. Post op
Calcium level an parathyroid hormone level is important in follow up after surgery.
Disease activity Serum calcium, phosphate and parathyroid hormone levels are important to assess disease activity. Disease activity
Serum calcium, phosphate and parathyroid hormone levels are important to assess disease activity.
DEXA scan Useful in patients who are known to have osteoporosis as a complication. DEXA scan
Useful in patients who are known to have osteoporosis as a complication.
Arterial blood gas Hyperchloremic metabolic acidosis occur in hyperparathyroidism. Arterial blood gas
Hyperchloremic metabolic acidosis occur in hyperparathyroidism.
Renal function tests(blood urea, serum creatinine, serum electrolytes) Loss of renal function is a can be a complication of hypercalcaemia, and phosphate retention. Renal function tests(blood urea, serum creatinine, serum electrolytes)
Loss of renal function is a can be a complication of hypercalcaemia, and phosphate retention.
Electrocardiogram Hypercalcaemia can cause shortening of QT interval and elevation of ST segment which can mimics acute myocardial infarction. Electrocardiogram
Hypercalcaemia can cause shortening of QT interval and elevation of ST segment which can mimics acute myocardial infarction.
Echocardiogram There can be left ventricular hypertrophy and myocardial calcific deposits. Echocardiogram
There can be left ventricular hypertrophy and myocardial calcific deposits.
DEXA scan (Dual-emission X-ray absorptiometry) This is to detect osteoporosis and Z -score <-2.0 forearm is suggestive of osteoporosis. DEXA scan (Dual-emission X-ray absorptiometry)
This is to detect osteoporosis and Z -score <-2.0 forearm is suggestive of osteoporosis.

Management - Supportive

Fact Explanation
Rehydration Management of emergency hypercalcaemic conditions, usually started with hydration. Rehydration
Management of emergency hypercalcaemic conditions, usually started with hydration.
Loop diuretics If the patients is having heart failure, diuretics are used to prevent fluid overload. Loop diuretics
If the patients is having heart failure, diuretics are used to prevent fluid overload.
Dialysis This is used for the patients with severe hypercalcemia presenting with kidney failure. Dialysis
This is used for the patients with severe hypercalcemia presenting with kidney failure.
Prevention of falls As the people with primary hyperparathyroidism ishaving osteoporosis, they are vulnerable to fractures, therefore measures shoul be taken to prevent falls and fractures. Prevention of falls
As the people with primary hyperparathyroidism ishaving osteoporosis, they are vulnerable to fractures, therefore measures shoul be taken to prevent falls and fractures.

Management - Specific

Fact Explanation
Management of hypercalcemic emergency Adequate rehydration is the first step in the management of hypercalcaemia. Then calcium excretion is achieved by furosemide combined with calcitionin. Bisphosphonates are also given as a slo.w infusion Management of hypercalcemic emergency
Adequate rehydration is the first step in the management of hypercalcaemia. Then calcium excretion is achieved by furosemide combined with calcitionin. Bisphosphonates are also given as a slo.w infusion
Surgical management-Parathyroidectomy Parathyroidectomy is a major mode of treatment for primary hyperparathyroidism. Studies have shown that the indications for the surgery would be significant hypercalcemia, impaired renal function, osteoporosis and age less than 50 years. Surgical management-Parathyroidectomy
Parathyroidectomy is a major mode of treatment for primary hyperparathyroidism. Studies have shown that the indications for the surgery would be significant hypercalcemia, impaired renal function, osteoporosis and age less than 50 years.
Medical management of primary hyperparathyroidism If the patient is not suitable for surgery, medical management is warranted. Methods used are bisphosphonates, calcitonin and calcimimetics. Medical management of primary hyperparathyroidism
If the patient is not suitable for surgery, medical management is warranted. Methods used are bisphosphonates, calcitonin and calcimimetics.
Bisphosphonates Patients with severe or symptomatic hypercalcemia, need biphosphonate to acheive the long term control. Zoledronic acid and pamidronate are examples of such bisphosphonates. . These are inhibitors of osteoclast-mediated bone resorption. Side effects include avascular mandibular osteonecrosis, gastrointestinal discomfort, acute influenza-like illness and occasionaly renal complications Bisphosphonates
Patients with severe or symptomatic hypercalcemia, need biphosphonate to acheive the long term control. Zoledronic acid and pamidronate are examples of such bisphosphonates. . These are inhibitors of osteoclast-mediated bone resorption. Side effects include avascular mandibular osteonecrosis, gastrointestinal discomfort, acute influenza-like illness and occasionaly renal complications
Calcitonin CalcitoninCalcitonin is given for the immediate management of hypercalcemia. It reduces both calcium and phosphate levels in the blood. Usually there are no serious adverse effects. Calcitonin
CalcitoninCalcitonin is given for the immediate management of hypercalcemia. It reduces both calcium and phosphate levels in the blood. Usually there are no serious adverse effects.
Calcimimetics Calcimimetics are useful agents in reversing the cortical bone loss by enhancing the sensitivity of calcium sensing receptors. Cinacalcet is one such examples calcimimetics. Side effects are nausea, vomiting and hypocalcemia. Calcimimetics
Calcimimetics are useful agents in reversing the cortical bone loss by enhancing the sensitivity of calcium sensing receptors. Cinacalcet is one such examples calcimimetics. Side effects are nausea, vomiting and hypocalcemia.

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