Updated: 6/18/2021

Hyperparathyroidism

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Evidence
6
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Cases
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https://upload.orthobullets.com/topic/9089/images/subperiosteal_resorption.jpg
  • summary
    • Hyperparathyroidism is the increase in serum parathyroid hormone (PTH) production that may be of primary, secondary or tertiary causes. 
    • Diagnosis is made based on evaluation of serum labs and clinical evaluation.
    • Treatment can be medical management or tumor resection depending on underlying cause of disease. 
  • Epidemiology
    • Incidence
      • occurs in 0.1% of the population
      • 90% result form a single adenoma
      • remaining 10% from parathyroid hyperplasia
    • Demographics
      • more common in women
      • hyperparathyroidism and malignancy make up the majority of patients with hypercalcemia
  • Etiology
    • Pathophysiology
      • PTH indirectly stimulates osteoclasts by binding to its receptor on osteoblasts, inducing RANK-L and M-CSF synthesis
      • Excessive PTH leads to over-stimulation of bone resorption
        • cortical bone affected more than cancellous
    • Associated conditions
      • Brown tumor
        • resembles a giant cell tumor of bone relating to focal demineralization of bone in the setting of hyperparathyroidism.
  • Classification
    • Primary
      • typically the result of hypersecretion of PTH by a parathyroid adenoma/hyperplasia
      • may result in osteitis fibrosa cystica
        • breakdown of bone, predominently subperiosteal bone
        • commonly involves the jaw
    • Secondary
      • secondary parathyroid hyperplasia as compensation from hypocalcemia or hyperphosphatemia
        • ↓ gut Ca2+ absorption
        • ↑ phosphorous
      • associated conditions
        • chronic renal disease
          • renal disease causes hypovitaminosis D
            • leads to ↓ Ca2+ absorption
        • renal osteodystrophy
          • bone leisons due to secondary hyperparathyroidism
    • Tertiary
      • parathyroid glands become dysregulated after secondary hyperparathyroidism
        • secrete PTH regardless of Ca2+ level
      • Primary, Secondary and Tertiary hyperparathyroidism
        Serum Ca
        Serum Phos
        Serum PTH
        Primary
        Increased
        Decreased
        Increased
        Secondary
        Normal or decreased
        Increased
        Increased
        Tertiary
        Increased
        Increased
        Increased
  • Presentation
    • Symptoms
      • often asymptomatic
      • weakness
      • kidney stones ("stones")
      • bone pain ("bones")
      • constipations ("groans")
      • uncommon cause of secondary hypertension
  • Evaluation
    • Serology
      • primary
        • hypercalcemia
        • ↑ PTH
      • secondary
        • hypocalcemia/normocalcemia
        • ↑ PTH
      • malignancy
        • ↓ PTH
      • ↑ alkaline phosphatase
      • normal anion gap metabolic acidosis
        • ↓ renal reclamation of bicarbonate
    • Urinalysis
      • primary
        • hypercalciuria (renal stones)
        • ↑ cAMP
    • Radiograph
      • cystic bone spaces ("salt and pepper")
        • often in the skull
      • loss of phalange bone mass
        • ↑ concavity (see key image of this topic)
    • EKG
      • shortened QT
  • Treatment
    • Acute hypercalcemia
      • IV fluids
      • Loop diuretics
    • Symptomatic hypercalcemia is treated surgically
      • treat with parathyroidectoy
      • complications include post-op hypocalcemia
      • manifests as numbness, tingling, and muscle cramps
      • should be treated with IV calcium gluconate
  • Complications
    • Peptic ulcer disease
      • ↑ gastrin production stimulated by ↑ Ca2+
    • Acute pancreatitis
      • ↑ lipase activity stimulated by ↑ Ca2+
    • CNS dysfunction
      • anxiety, confusion, coma
      • result of metastatic calcification of the brain
    • Osteoporosis
      • bone loss occurs as result of bone resorption due to excess PTH
      • orthopedic surgeons should recognize lab abnormalities as patients may present with fragility fractures
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(OBQ13.185) A 25-year-old female presents to the emergency room within increasing left shoulder pain after walking into a door 5 months ago. She previously sustained a femoral fracture 2 years ago after tripping on a rug. Relevant skeletal survey radiographs and tissue biopsy results are shown in Figures A through D. Laboratory investigations show normal glomerular filtration rate and creatinine clearance. Dual energy x-ray absorptiometry (DEXA) scan shows T-score of -1.4 and -1.2 at the hip and lumbar spine, respectively. Which of the following laboratory values in Figure E most likely reflects this patient's condition?

QID: 4820
FIGURES:
1

A

46%

(1975/4268)

2

B

24%

(1044/4268)

3

C

14%

(581/4268)

4

D

9%

(368/4268)

5

E

6%

(240/4268)

L 4 B

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(OBQ11.57) A 35-year-old female complains of 1 month of right hip pain during ambulation. Her medical history includes end-stage renal disease for which she is on hemodialysis three times per week. A radiograph of the right hip, spine, and skull are shown in Figures A-C. Figure D shows a histology microphotograph of a biopsy specimen. All of the following laboratory findings are associated with this condition EXCEPT?

QID: 3480
FIGURES:
1

Hypophosphatemia

49%

(1348/2745)

2

Hypocalcemia

19%

(533/2745)

3

Decreased 1,25-(OH)2-vitamin D3

9%

(245/2745)

4

Increased alkaline phosphatase

14%

(378/2745)

5

Increased BUN

8%

(226/2745)

L 4 C

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