1) The patient presented with hypercalcemia, hypophosphatemia, and increased alkaline phosphatase levels in their blood and hypercalciuria and hyperphosphaturia in their urine. Imaging and biopsy revealed a single adenoma in the parathyroid gland. 2) Various tests were performed to diagnose primary hyperparathyroidism including 24-hour urinary calcium, phosphate excretion tests, and isotope scans which localized the parathyroid adenoma. 3) Treatment options included acute rehydration and medication management as well as minimally invasive parathyroidectomy surgery to remove the adenoma causing the hyperparathyroidism.

1. DR MOHAMMED SHAHID

2.  BLOOD: Hypercalcemia
Hypophosphatemia
ALP- increased
 URINE: Hypercalciuria
Hyperphosphaturia
 HPE: single adenoma-mc,
pale, clear-chief cells
 ECG: short QT interval
 USG & Tc99 SESTAMIBI SCAN

3.  24hr urinary calcium:
• Differentiates pHPT from familial hypocalciuric
hypercalcemia
 Phosphate excretion test:
• PTHdecreases net tubular phosphorous
reabsorptionphosphaturia.
 Phosphorous loading test:
• In case of poor intake or poor absorption, there is normal
phosphorous excretion
• Oral phosphorous (2-3g over 3days)  decreases tubular
phosphorous reabsorption phosphaturia

4.  Cortisone suppression test:
• Administration of steroids (150mg cortisone per day for
10days)  no effect on hypercalcemia of
hyperparathyroidism in contrast to sarcoidosis, multiple
myeloma, hypervit D
 Urinary Hydroxyproline: markedly raised. attributed to
increased bone turnover and collagen degradation.
 Isotope studies:
• Se-75 (selenomethionine) scan detects abnormal
parathyroid tissue
 RIA: radiolabelled antibodies directed against PTH. More
specific.

5.  M/C : generalized osteopenia
 Bone resorption- subperiosteal, intracortical,
trabecular, endosteal, subchondral, subligamentous, or
subtendinous.
 Bone sclerosis
 Brown tumors
 Chondrocalcinosis
 Soft tissue calcification and vascular calcification.

6. •M/c -Radial aspects of the
middle phalanges.
•Phalangeal tufts.
•Distal end of the clavicle
•Medial tibial & humeral
metaphysis.
•Medial femoral neck
•Superior & inferior margins
of ribs.

7. Spotty de-ossification- salt & pepper appearance

8. •Iliac side of SI joint.
•DIP joint(m/c- ring &
little fingers).
•MCP joint.
•Clavicular side of AC
joint.

9. Scalloping along the cortex
M/c in long bones

10. •Expansile lytic lesion with
well defined non sclerotic
margin
•Replacement of bone by
vascularized fibrous tissue-
osteoclastic activity

11. •m/c in secondary
hyperparathyroidism
• horizontal, bandlike
("rugger jersey")
sclerosis.

12. Ca PTH P ALP
PHPT
SECONDARY
HPT (CKD)
(soft
tissue
deposition)
MILK ALKALI /N N
MALIGNANCY /N
PAGET’S N N N
RICKETS

13.  Acute hypercalcemia -rehydration with normal saline,
reduced calcium intake, haemodialysis.
 Loop diuretics
 Avoid thiazide diuretics.
 Monitor serum creatinine levels
and calcium levels every 6 months.
 DEXA scan on an annual basis.

14.  Calcimimetics: mimics calcium by stimulating calcium
sensors -> less PTH release.
• Side effects: joint and muscle pain, diarrhea, nausea, and
respiratory infection.
 Bisphosphonates: decreases osteoclastic bone resorption,
osteo protective.
• Side effects: low blood pressure, fever and vomiting.

15.  Surgery :
- Symptomatic hyperparathyroidism
-Asymptomatic hyperparathyroidism with:
◦ 24-hour urinary calcium > 400 mg
◦ serum calcium > 1 mg/dl above upper limit of normal
◦ Creatinine clearance > 30% below normal for patient's age
◦ Bone density > 2.5 SD below peak (i.e., T-score of -2.5)
◦ People age < 50
 Minimally invasive surgery - solitary adenoma,
 Subtotal parathyroidectomy - diffuse hyperplasia.

16.  “Hungry Bone Syndrome”- postoperative, prolonged (>4days),
profound hypocalcemia (<8.4 mg/dL) -osteoblastic activity.
 Can also present in men metastatic prostate cancer.
 Presents with hypocalcemic tetany.
 Rx- bolus 10% ca. gluconate 10-20 mL in 50-100 mL of 5%-D IV
over 5-10 minutes(100 to 200 mg of elemental calcium.)
 Continuous infusion- 100cc of 10% ca.gluconate in 1L of
5%D (1 mg/mL of elemental calcium.)
 Start at 50 ml/hr and follow Ca, phosphorus, and magnesium
levels titrating every 4-6 hours.

17. SECONDARY HYPERPARATHYROIDISM:
 Correcting vitamin D deficiency.
 Treatment of chronic kidney disease (Calcium
supplementation)
TERTIARY HYPERPARATHYROIDISM:
 Total or subtotal parathyroidectomy.
 Autotransplantation
PATHOLOGICAL/STRESS FRACTURES:
 immediate immobilisation – treat the primary cause.
 Bisphosphonate therapy

18. THANK YOU