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A Symptoms and Signs
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Hypercalcemia is typically discovered accidentally by routine chemistry panels Most patients are asymptomatic Parathyroid adenomas are usually so small and deeply located in the neck that they are almost never palpable; when a mass is palpated, it usually turns out to be an incidental thyroid nodule Although many patients with mild hypercalcemia offer no complaints, symptomatic patients are said to have problems with bones, stones, abdominal groans, psychic moans, with fatigue overtones The manifestations are categorized as skeletal, urinary tract, and those associated with hypercalcemia 1 Skeletal manifestations Hyperparathyroidism causes a loss of cortical bone and a gain of trabecular bone Significant bone demineralization is uncommon in mild hyperparathyroidism, but osteitis fibrosa cystica may present as pathologic fractures or as brown tumors or cysts of the jaw More commonly, patients have bone pain and arthralgias 2 Urinary tract manifestations Polyuria and polydipsia may be present and are due to hypercalcemia-induced nephrogenic diabetes insipidus Calcium-containing kidney stones are reported in about 18% of those with newly discovered primary hyperparathyroidism Nephrocalcinosis and renal failure can occur 3 Manifestations of hypercalcemia Mild hypercalcemia is often asymptomatic In more severe cases, thirst, anorexia, nausea, and vomiting are present Constipation, fatigue, anemia, weight loss, and hypertension are commonly found Pancreatitis occurs in 3% Some patients have neuromuscular disorders such as muscle weakness, easy fatigability, or paresthesias Depression, intellectual weariness, and increased sleep requirement are common Pruritus and psychosis or even coma may accompany severe hypercalcemia Calcium may precipitate in the corneas ( band keratopathy ) or soft tissue (calciphylaxis) 4 Hyperparathyroidism during pregnancy About 67% of women with primary hyperparathyroidism during pregnancy experience complications such as nephrolithiasis, hyperemesis, pancreatitis, muscle weakness, cognitive changes, and hypercalcemic crisis About 80% of fetuses experience complications of maternal hyperparathyroidism, including fetal demise, preterm delivery, low birth weight, postpartum neonatal tetany, and permanent hypoparathyroidism
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Preoperative sestamibi-iodine subtraction scanning and neck ultrasonography have been used to locate parathyroid adenomas in patients with hyperparathyroidism, in an effort to improve the outcome and limit the invasiveness of neck surgery Parathyroid imaging is crucial for patients who have had prior neck surgery However, the usefulness of preoperative parathyroid localizing imaging studies for first neck explorations remains controversial Imaging is not useful for the diagnosis of hyperparathyroidism, which must be made by serum calcium and PTH determinations Preoperative scanning does not improve the outcome of initial bilateral neck explorations performed by a surgeon with special expertise in parathyroid surgery Therefore, preoperative imaging has been used mainly to improve the outcome for limited neck exploration, with only modest success See Surgery, below Small benign thyroid nodules are discovered incidentally in nearly 50% of patients with hyperparathyroidism who have imaging with ultrasound or MRI CT and MRI scanning are not ordinarily required or useful for initial preoperative parathyroid localizing studies, since these scanning techniques are less sensitive for identifying tiny parathyroid adenomas However, for repeat neck operations and when ectopic parathyroids are suspected, MRI is preferred since it offers better soft tissue contrast than CT scanning and is less adversely affected by postoperative
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B Laboratory Findings
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The hallmark of primary hyperparathyroidism is hypercalcemia: serum calcium > 105 mg/dL or ionized calcium In hyperproteinemic states, the total serum calcium may be elevated but the ionized fraction is normal, whereas in primary hyperparathyroidism, the ionized calcium is almost always over 54 mg/dL (14 mmol/L) In practice, serum ionized calcium determinations have not proved to be very
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changes in the neck Three-dimensional technetium-99m sestamibi scanning can also help localize ectopic parathyroid glands Bone radiographs are usually normal and are not required to make the diagnosis of hyperparathyroidism There may be demineralization, subperiosteal resorption of bone (especially in the radial aspects of the fingers), or loss of the lamina dura of the teeth There may be cysts throughout the skeleton, mottling of the skull ( salt-and-pepper appearance ), or pathologic fractures Articular cartilage calcification (chondrocalcinosis) is sometimes found Patients with renal osteodystrophy may have ectopic calcifications around joints or in soft tissue Such patients may exhibit radiographic changes of osteopenia, osteitis fibrosa, or osteosclerosis, alone or in combination Osteosclerosis of the vertebral bodies is known as rugger jersey spine
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