Hyper Parathyroidism- In Ortho

8/9/2019 Hyper Parathyroidism- In Ortho

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INTRODUCTION

Caused by elevated secretion of PTH

Primary hyperparathyroidism- most common cause for asymptomatic

hyperparathyroidism

Incidence 1%. Females predominate

Peak age- 3rd to 5th decade

Shown declining trend in past few decades


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CLASSIFICATION


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PRIMARY HPT


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SECONDARY HTP

CHRONIC RENALFAILURE

LITHIUM TOXICITY MALIGNANCY

HYPOCALCEMIA VIT D DEFICIENCY


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HEREDITARY PRIMARY HTP


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SYMPTOMS


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BONE INVOLVEMENT

Brown tumor

von Recklinghausen's disease of bone

Osteitis fibrosa cystica


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investigations

Diagnosis entirely by laboratory studies

Advanced Imaging modalities used only for localization

when limited parathyroid exploration is chosen to remove

the affected gland only or in patiens with recurrence post

previous surgery

Plain X ray studies and histological studies are only

supportive investigations


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DIAGNOSIS- lab studies

1. serum PTH level

Normal 10-55 pg/ml

Elevated in 80-90% of PHPT

Definitive diagnosis

Max value in PHPT

normal or marginally elevated in FHH

SHPT in malignancies (small cell ca lung) release

PTHrP...undetected by PTH assays


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2. Serum calcium level 11-13mg/dl- asymptomatic

13-15mg/dl- metastatic calcification

>15mg/dl- cardiac arrest, coma Persistent hypercalcemia(>1 occasion)

If serum calcium normal, go for serum ionized calcium level

24 hour calcium quantification (


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Calcium levels normal in SHPT

In subset of PHPT, calcium levels normal-normocalcemic HPT..

Diagnosed only after excluding SHPT

3.SERUM PHOSPHATE

NORMAL 2.4-4.1 mg/dl

Level decreased


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4. Serum alkaline phosphatase

Normal 44- 147 IU/ml

Due to increased bone turn over

5. Serum hydroxyproline

Elevated due to bone metabolism

Normal 0.9-21mg/dl

6. Mild hyperchloremic acidosis


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Diagnostic algorithm


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imaging studies

1.Plain X ray studies

a) Subperiosteal erosions in radial aspect of middle phalanges

of index and middle fingers

Other sites: terminal phalanx, acromio clavicular jt, pubic

symphisis, sacroiliac jt

b) Acro osteolysis ( phalangeal tuff resorption)


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b) True bone cyst- fluid filled cavity lined by fibrosis underperiosteum

Brown tumors containing poorly mineralized woven

bone and hemosiderin( common maxilla/ mandible)

3) Loss of lamina dura around teeth (80%)

4) In elderly, diffuse osteopenia ( non homogenous,

mottled or salt n pepper appearance) esp. in skull


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Localizing radiologic study

1) Technetium-99m (99mTc) sestamibi radionuclide scan

Stays in normal tissue up to 1 hour

Delayed persistence in parathyroid adenomas

Sensitivity upto 90% normally

Only 50% in multiglandular disease


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2) USG

equally sensitive

rapid evaluation but accuracy is operator dependant

not sensitive in multiglandular disease

3) CT, MRI

4) Dual energy radiographic absorptiometry( bone)


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OTHERS

1) Selective venous sampling of neck veins and PTH assay fortumor localization

2) histopathology

Cortical cutting cones- spearhead arrangement ofosteoclasts boring cortex and widening haversion canals

Dissecting osteitis- in cancellous bone tunelling along

length of trabeculae- rail road appearance


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TREATMENT OUTLINE

surgical exploration and removal

medical management to promote bone mineralisation

(raloxifen, bisphosphonate, calcitriol, calcitonin)

CASR receptor agonist- TERIPARATIDE, CINACALCET

treatment of pathological fractures, renal calculi,

peptic ulcer etc.


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Hyper Parathyroidism- In Ortho

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