HYPERPARATHYROIDISM Shariati Thursday Conference 86 12 16

HYPERPARATHYROIDISMHYPERPARATHYROIDISM

Shariati Thursday Conference86 12 16

ParaThyroid Hormone (PTH) Biochemistry Physiology pathophysiology

Hyperparathyroidism Clinical manifestation Diagnosis

◦Lab finding◦ imaging

treatment

Biochemistry

Parathyroid Glands (4 glands 6*3*2 mm.)

84 aa protein (9500 D)

Receptor in target cell (osteoblast, osteoclast, renal tubules)

cAMP enzym release reaction catalysis

Physiology

GI intake

Urinary out put

Bone

PTHVit DCalcitonin

GISweat

GI intake

Urinary out put

Bone

GISweat

Physiology

400-1000mg

10-70%

100-300mg>4mg/kg abn.

7g98%

Vit D

GI intake

Urinary out put

Bone Ca

GISweat

Physiology

.

99%=1-2kg

Intra cellular Ca 0.1%

1%Pr.Bound Ca 40%Non-ionized Ca 10%Ionized Ca 40%

Bone Ca

Kidney Ca

GI Ca

In minutes Osteocyt&blast

In days Osteoclast

Pathophysiology◦Primary hyperpara◦Secondary hyperpara◦Tertiary hyperpara

◦pseudohyperpara

Pathophysiology◦Primary hyperpara

◦Diffiuse hyperplasia 10-40%◦Single adenoma 50-80%◦Multiple adenoma 10%◦Carcinoma 1%

◦Secondary hyperpara◦Tertiary hyperpara

◦pseudohyperpara

Pathophysiology◦Primary hyperpara◦Secondary hyperpara

◦Secondary to hypocalcemia Renal dysfunction P Malabsorption P

◦Tertiary hyperpara

◦pseudohyperpara

Pathophysiology◦Primary hyperpara◦Secondary hyperpara◦Tertiary hyperpara

◦Autonomus hyperactivity after secondary hyperpara

◦pseudohyperpara

Pathophysiology◦Primary hyperpara◦Secondary hyperpara◦Tertiary hyperpara

◦pseudohyperpara ◦Hypercalcemia of malignancy

without metastasisor primary hyperpara

Pathophysiology◦Primary hyperpara Ca / N ◦Secondary hyperpara Ca / N◦Tertiary hyperpara

◦pseudohyperpara

Pathophysiology

◦Osteoclast/Osteoblast

◦Osteoclast activity◦Osteoblast activity

◦Remodeling activity

Clinic

100,000 new case / year in USA 1/1000

4th and 6th decade F/M = 2/1

Clinical findings:

◦Renal◦Gastrointestinal◦Skeletal manifestation

◦CNS◦Skin◦Cardiovascular

◦hypercalcaemia

common

rare

nowadays

Renal Urinary tract calculi Nephrolithiasis

Gastrointestinal Peptic ulcer Pancreatitis

Skeletal 10-25% Tenderness Aching pain (peripheral joints & vertebrae) Sever pain, swelling, deformity

Rare manifestations:

CNSPersonal disturbance, coma, fatigue

SkinDry skin, itching

CardiovascularHypertension, CHF

Lab exam,

◦Ca◦P◦Alk Ph.◦Urin Ca

Lab exam,

◦Ca PrimaryUp-N Secondary N-Low

Total Ca 50% ionic calcium (acidosis, hypoproteinemia)◦P◦Alk Ph.◦Urin Ca

◦PTH

Lab exam,

◦Ca◦P

◦Primary Low◦Secondary Up/Low

◦Alk Ph.◦Urin Ca

◦PTH

Lab exam,

◦Ca◦P◦Alk Ph.

◦Hyperphosphatesia

◦Urin Ca

◦PTH

Lab exam,

◦Ca◦P◦Alk Ph.◦Urin Ca.

◦Hypercalciurea

◦PTH

Lab exam,

◦Ca◦P◦Alk Ph.◦Urin Ca.

◦PTH ◦Up ◦Rarely N

Radiologic findings,

◦Bone resorption

◦Bone survey Bone resorption of hand is highly sensitive If

high qualitymacroradiography/digitalized radiograhy

◦Bone densitometry

Radiologic findings,

◦Bone resorption

◦Bone survey Bone resorption of hand is highly sensitive If

high qualitymacroradiography/digitalized radiograhy

◦Bone densitometry

Bone resorption Subperiosteal Juxtaarticular Intraarticular, (high turn over, hyperthyroidism) Subchondral Endosteal, (MM, Osteoporosis) Subphysial Trabecular Sublig. And sub tendinous Brown tumor

Bone resorptionSubperiosteal Juxtaarticular Intraarticular, (high turn over, hyperthyroidism) Subchondral Endosteal, (MM, Osteoporosis) SubphysialTrabecular Sublig. And sub tendinousBrown tumor

Subperiosteal resorption

Diagnostic (prominent) DD: chronic renal disease Radial aspect of the hand phalanx

Middle phalanx Index & middle finger

Subperioseal resorption

Progressive

lace like appearance

Subperioseal resorption

Progressive

lace like appearance

speculated contour

Subperioseal resorption

Progressive

lace like appearance

speculated contour

complete resorption of cortex

Subperiosteal resorption

Other sites; Phalanx tuft Medial proximal tibia, femur,humerus Upper and lower border of the rib Lamina dura

Subperiosteal resorption

Other sites; Phalanx tuft Medial proximal tibia, femur,humerus Upper and lower border of the rib Lamina dura

Subperiosteal resorption

Phalanx tuft, acro-osteolysis

Subperiosteal resorption

Phalanx tuft, acro-osteolysis

Subperiosteal resorption

Phalanx tuft, acro-osteolysis

Trabecular resorption

Medullary bone In advance stages Granular appearance

In cranium is caractristic osteopenia+speckled appear=Salt and Pepper

Trabecular resorption

Brown tumor

Osteoclastoma Specially in primary hyperpara

Fibrous tissue+giant cells

Radiologic app.◦Single or multiple◦Well defined◦Axial or appendicular skeleton◦Cortical or eccentric◦Could be expansile◦Common sites; face bones, pelvis, rib, femur

Brown tumor

Usually after other signs Occasionally as presenting finding

Diagnosis

◦Lab exam Ca PTH

◦Preoperative study Tc labeled Sestamibi

Treatment

◦Surgery

◦Adenoma resection◦Resection of 3.5 gland

◦Post operative care

Thank you for your attention