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

CLASSIFICATION
PRIMARY HPT
SECONDARY HTP

CHRONIC RENAL
LITHIUM TOXICITY MALIGNANCY
FAILURE

HYPOCALCEMIA VIT D DEFICIENCY

HEREDITARY PRIMARY HTP
SYMPTOMS
BONE INVOLVEMENT

• Brown tumor
• von Recklinghausen's disease of bone
• Osteitis fibrosa cystica
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
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
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 (<100 mg) 0r Ca/Cr
clearance ratio (<0.01 in 90%) in FHH
• 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
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
Diagnostic algorithm
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)
b) True bone cyst- fluid filled cavity lined by fibrosis under
periosteum
• 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
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
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)
OTHERS

1) Selective venous sampling of neck veins and PTH assay for

tumor localization
2) histopathology
• Cortical cutting cones- spearhead arrangement of
osteoclasts boring cortex and widening haversion canals
• Dissecting osteitis- in cancellous bone… tunelling along
length of trabeculae- rail road appearance
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.