Hyperparathyroidism Disease

BASICS

DESCRIPTION

Hyperparathyroidism represents a loss in control of the body's normal regulatory feedback mechanism on the parathyroid glands and their ability to maintain a normal serum calcium

Primary hyperparathyroidism - direct hyperfunction of the parathyroid glands due to either glandular hyperplasia or adenoma
Secondary hyperparathyroidism - usually found in chronic renal disease or vitamin D deficient states which cause hyperplasia of all four glands and associated increase in activity
Multiple endocrine neoplasia (MEN syndromes) - disease states with associated endocrine malfunctions with parathyroid gland hyperplasia leading to a hyperparathyroid state
Parathyroid carcinoma - extremely rare
System(s) affected: Endocrine/Metabolic
Genetics: N/A
Incidence/Prevalence in USA:
- Rare in children
- Male adults 60 years or older - 100 cases/100,000
- Female adults 60 years or older - 300-400 cases/100,000
- All-age adjusted incidence - 42 cases/100,000
- Prevalence all ages - 250 cases/100,000 population
Predominant age: Age greater than 50
Predominant sex: Females > Males (4:1)

SIGNS AND SYMPTOMS

"Painful bones, renal stones, abdominal groans and psychic moans." You must think of it to diagnose it.
Renal:
- Nephrolithiasis
- Nephrocalcinosis
- Reduced glomerular filtration rate
- Thirst
- Polydipsia
- Polyuria
Gastrointestinal:
- Abdominal distress
- Gastroduodenal ulcer
- Pancreatitis
- Pancreatic calcification
- Constipation
- Vomiting
- Anorexia
- Weight loss
Skeletal:
- Bone pain and tenderness
- Cystic bone lesions
- Skeletal demineralization
- Spontaneous fracture
- Vertebral collapse
- Osteoporosis
Mental:
- Fatigue
- Apathy
- Anxiety
- Depression
- Psychosis
Neurologic:
- Somnolence
- Coma
- Diffuse EEG abnormalities
Neuromuscular:
- Muscle fatigue
- Weakness
- Hypotonia
Cardiovascular:
- Hypertension
- Short QT interval
Articular/periarticular:
- Arthralgia
- Gout
- Pseudogout
- Periarticular calcification
Ocular:
- Band keratopathy
- Conjunctivitis
- Conjunctival calcium deposits

CAUSES

Primary hyperparathyroidism
- Caused by usually one but sometimes multiple parathyroid gland hyperplasia or adenomatous changes which cause an unregulated increase of parathyroid hormone (PTH) production and release, causing increase in serum calcium
Secondary hyperparathyroidism
- Seen most often in chronic renal failure because of adaptive parathyroid gland hyperplasia and hyperfunction
- Renal parenchymal loss resulting in hyperphosphatemia
- Impaired calcitriol production leading to hypocalcemia
- General skeletal and renal resistance to PTH for reasons unknown

RISK FACTORS

Age greater than 50
Female
Occurs more frequently in temperate than tropical climates
Higher incidence in people exposed to therapeutic low dose radiation

DIAGNOSIS

LABORATORY

Elevated serum calcium greater than 10.2 mg/dL (2.55 mmol/L) on 3 successive measurements
Elevated serum immunoreactive parathyroid hormone (iPTH) levels
Low serum phosphate levels, less than 2.5 mg/dL (0.81 mmol/L)
Elevated serum chloride levels
Decreased serum CO2
Hyperchloremic metabolic acidosis
Increase in urinary cyclic AMP

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Parathyroid hyperplasia - all parathyroid glands with cellular changes
Parathyroid adenoma - only one gland usually with cellular changes
Parathyroid carcinoma - cellular changes consistent with malignancy, i.e., cellular atypia, lymph node changes

SPECIAL TESTS

Immunoassay directed against intact PTH molecule

IMAGING

Neck ultrasonography
Thallium technetium scanning
Magnetic resonance imaging
CT scanning with and without contrast
Sestamibi scan for neck

DIAGNOSTIC PROCEDURES

Percutaneous needle biopsy aspiration for cytology and PTH determination
Open surgical removal with frozen section diagnosis

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient usually. Inpatient for surgery or for treatment of underlying cause.

GENERAL MEASURES

A few patients with mild asymptomatic hypercalcemia due to hyperparathyroidism may not be candidates for surgery and may be managed conservatively. Avoiding dehydration is the most important treatment.

SURGICAL MEASURES

Surgical removal of diseased gland is only proven curative therapy for hyperparathyroidism (subtotal resection)
In preoperative and immediately postoperative patients, large fluid intake is indicated to help prevent formation of renal stones
Open neck surgical exploration advocated approach
Removal of obviously diseased gland with biopsies of other glands to make sure physiologically viable
Total resection of all four glands with transplantation of normal gland to forearm advocated by some
Special attention must be made during exploration and removal of parathyroid glands for ectopic gland in the neck area
Postoperative course needs special attention paid to airway and risk of airway compromise
Monitoring renal functions closely

ACTIVITY

As tolerated

DIET

As indicated by condition of patient

PATIENT EDUCATION

Educate about medications
Importance of periodic lab exams

FOLLOW UP

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS

Skeletal damage (pathologic fractures)
Renal damage
Urinary tract infections
"Parathyroid poisoning"
Hypertension
From surgery:
- Hypoparathyroidism
- Recurrent laryngeal nerve damage
- Bleeding
- Infection
- Unsuccessful surgery (5%)

EXPECTED COURSE AND PROGNOSIS

Postoperative course requires following of serum calcium to make sure hyperparathyroid state does not redevelop
Prognosis is excellent in primary hyperparathyroidism with resolution of many of the preoperative symptoms
Secondary hyperparathyroidism carries a poor prognosis because of the primary disease state of chronic renal failure

MISCELLANEOUS

ASSOCIATED CONDITIONS

Multiple endocrine neoplasia (MEN) syndromes

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric:

Common in the elderly
More likely to have a secondary disease
May cause confusion and be interpreted as senile dementia

Others: N/A

PREGNANCY

Rarely occurs during pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

PTH = parathyroid hormone

Clinical Investigations

ROLE OF HOMOEOPATHY

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