1. HyperparathyroidismHyperparathyroidism

2. Report of A Case Chart No, 1060760-9 Name: X Chief Complaint : hypercalcemia for etiological study Present Illness This 24-year-old man was rather well before. Hypertension was noted when he underwent a heath examination for military service. On tracing the related history, he stated he had suffered from renal stone with colic pain for many times. Physcal exam revealed BW 78.6kg, BH 172cm, BP 165/100mmHg.Lab exam revealed serum Ca of 11.4mg/dl (N: 8.1-10.1), P 2.8mg/dl (2.5-5.0), iPTH 87pg/ml (N: 8-74 ). Under the impression of primary hyperparathyroidism, he was admitted for the further studying. T-J WU 3. Imaging Studies (1) The parathyroid sonography (93.10.19) showed an enlarged left parathyroid gland, size 0.7cm. 201 Tl99m Tc subtraction parathyroid scan shows no abnormal uptake of tracer in the anterior neck. Imp : no evidence of parathyroid or hyperplasia in the anterior neck. T-J WU 4. ThalliumThallium 201201 TlTl TechnetiumTechnetium 99m99m TcTc Pertechnetate Subtraction ScanPertechnetate Subtraction Scan T-J WU 5. Lab Studies Urine Ca 13.0 mg/dl ; Cr 61.6 mg/dl; amunt 3050ml Plasma Ca 11.1mg/dl, P 2.4 mg/dl, Cr 0.8mg/dl; Alb 4.5g/dl; Osmo: 297 mOsmo/kg The parathyroid sonography (93.10.19) showed an enlarged left parathyroid gland, size 0.5cm. Magnetic resonance imaging (MRI) revealed no evidence of parathyroid adenoma. T-J WU 6. Imaging Studies (VGH) The parathyroid sonography (93.5.18): A hypoecholc nodule about 0.5x0.3cm was found posterior to left lobe of thyroid gland, showing minimal marginal color flow signals, cannot R/O slightly enlarged left side superior parathyroid gland, which may be associated with adenoma. Recommend check the iPTH level, and nuclear medicine study correlation. The Tc-99m MIBI scintigraphy shows faint uptake in the left thyroid bed in the delayed image 3 hrs after injection). Impression In view of the small size of nodule < 0.5 cm and its posterior localization, the possibility of parathyroid adenoma cannot be completely ruled out. T-J WU 7. Technetium Tc 99m methoxyisobutyl isonitrile (99m Tc MIBI). DelayedTc 99m -MIBI image Early images 8. Anatomy and Physiology of Parathyroid Although the number and position can vary, there are usually 4 parathyroid glands which are usually located behind the thyroid. Parathyroid hormone consists of 84 amino acids derived from a prohormone. The effects of parathyroid hormone on serum calcium are mediated by increasing renal tubular resorption of calcium, increasing calcium absorption from the intestines (via vitamin D) and increasing release of calcium from bone. A negative feedback mechanism normally decreases production of parathyroid hormone as the ionized serum calcium level increases. Disease states with altered protein binding require a correction factor to determine the ionized calcium level from the total calcium level. A low measured calcium with low albumin may be corrected by adding 0.8 mg per dL (0.2 mmol per L) of calcium for each gram per dL that the albumin is below 4 g per dL (1 mmol per L). Alternatively, the serum ionized calcium level can be measured directly. T-J WU 9. Effects of Hyperparathyroidism (1) Cardiovascular System Mortality from cardiovascular disease was higher Hypertrophic cardiomyopathy and a decrease in function of the muscles of respiration may account for some of this effect. Hypertension and congestive heart failure, and changes on EKG. Musculoskeletal System The bone loss involves the peripheral skeleton more than the vertebral bodies and affects cortical bone more than cancellous bone. Nonspecific myalgias are the most common symptoms. Osteitis fibrosa cystica ( brown tumors) mimic malignant lesions. Gastrointestinal System Anorexia, constipation and nausea can occur Peptic ulcer disease occurs in 15 % of patients. "parathyroid storm" (also referred to as parathyroid poisoning or parathyroid crisis). Pancreatitis is sometimes an additional manifestation of primary hyperparathyroidism. T-J WU 10. Effects of Hyperparathyroidism (2) Central Nervous System Mental disorders, especially depression, and central nervous system dysfunction are commonly associated with hypercalcemia and hyperparathyroidism. Several suicides have been attributed to hyperparathyroidism. Patients often feel better after removal of a dysfunctional parathyroid gland. Renal and Genitourinary Systems Nocturia and polyuria result from the effects of calcium on the renal tubule. 20 % of patients with hyperparathyroidism have kidney stones. Only 2 to 3 % of patients with kidney stones have hyperparathyroidism. Nephrolithiasis is more common in patients with the slow, insidious form of hyperparathyroidism. T-J WU 11. Pathology of HyperparathyroidismPathology of Hyperparathyroidism In 85 % of the patients, hyperparathyroidism is the result of an adenoma in a single parathyroid gland. Hyperplasia of all 4 parathyroid glands causes hyperparathyroidism in 15 % of patients. A very small number of cases result from parathyroid malignancies. The incidence of hyperparathyroidism is higher in patients with type I (with tumors of the pituitary and pancreas) and type II (pheochromocytoma, and medullary carcinoma) multiple endocrine neoplasia syndromes, in patients with familial hyperparathyroidism and in patients who received radiation therapy to the head and neck area for benign diseases during childhood. T-J WU 12. Guidelines for Recommendation forGuidelines for Recommendation for Surgical Treatment of HyperparathyroidismSurgical Treatment of Hyperparathyroidism Typical parathyroid-related symptoms involving skeletal, renal, GI or psychologic symptoms Markedly elevated serum calcium level (1 to 1.6 mg per dL above accepted normal range) History of an episode of life-threatening hypercalcemia Reduction of creatinine clearance by more than 30% History of nephrolithiasis Urinary calcium excretion > 400 mg /day Reduction of bone mass > 2 SD below normal Patient is young (