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Primary hyperparathyroidism – Quick review chart

Disorder of the parathyroid glands in which one or more of the parathyroid glands are enlarged ( hyperplastic ) , overactive and secrete too much parathyroid hormone.

 

relatively common endocrine disorder most common cause of hypercalcemia in ambulatory setting happens more commonly in women , age 50-60 studies have shown an annual incidence of 20 cases per 100,000 people with an estimated prevalence in the general population of 0.5 % to 1 % and this increase with age to over 2 % in both sexes

 

solitary parathyroid adenoma ( 80 % of cases ) diffuse hyperplasia and multiple adenomas familial disorders ( e,g MEN type 1 ,2A syndrome ) parathyroid carcinoma ( rare ) familial hypocalciuric hypercalcemia is a benign cause , autosomal dominant inheritance ( mimics PHPT )

 

Hypercalcemia and levels of PTH that are inappropriately high for the level of hypercalcemia ( normally the PTH level would be suppressed ) , in some cases the PTH can be within the reference range Even a normal PTH in presence of hypercalcemia is inappropriate and consistent with PTH-dependent hypercalcemia Previously patients were detected when they presented with complications as kidney stones , bone pain or deformity- now usually an incidental finding on routine testing

 

Differential diagnosis is complex and is with other conditions causing hypercalcemia and include metastatic cancer , multiple myeloma ,sarcoidosis

 

Symptomatic
hypercalcemia- seen less commonly due to routine screening in developing countries fragility fractures , recurrent nephrolithiasis , nephrocalcinosis , polyuria , renal insufficiency , osteopenia

 

Asymptomatic
hypercalcemia- most common presentation in the developed world , picked on routine screening

 

Normocalcemic PHPT- a group characterized by an elevated PTH with persistently normal conc’s of albumin adjusted total ionized calcium often found during assessment of osteoporosis or a fragility fracture.

 

symptoms of hypercalcemia osteoporosis or a previous fragility fracture renal stone chronic non-differentiated symptoms- 2.6 mmol/l on atleast 2 occasions OR 2.5 mmol/l or above on atleast 2 occasions and PHPT suspected.

 

PTH above the midpoint of reference range and PHPT is suspected OR below the mid point reference range with a concurrent albumin adjusted Ca 2.6 or above.

 

PTH is within the reference range but below the midpoint reference range AND their concurrent albumin adjusted Ca is < 2.6

 

Medical surveillance – annual calcium , creatinine and BMD measurement every 1-2 yrs , Management options include bisphosphonates , oestrogen replacement and cinacalcet.

REFERENCES

  1. Taniegra ED. Hyperparathyroidism. Am Fam Physician. 2004 Jan 15;69(2):333-9. PMID: 14765772. Hyperparathyroidism – PubMed (nih.gov)
  2. John P Bilezikian, Primary Hyperparathyroidism, The Journal of Clinical Endocrinology & Metabolism, Volume 103, Issue 11, November 2018, Pages 3993–4004, https://doi.org/10.1210/jc.2018-01225
  3. Pokhrel B, Levine SN. Primary Hyperparathyroidism. [Updated 2021 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441895/
  4. Pallan SRahman M OKhan A ADiagnosis and management of primary hyperparathyroidism doi:10.1136/bmj.e1013 Diagnosis and management of primary hyperparathyroidism | The BMJ
  5. Hyperparathyroidism (primary): diagnosis, assessment and initial management NICE guideline Published: 23 May 2019 *Hyperparathyroidism (primary): diagnosis, assessment and initial management (nice.org.uk)

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