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  • • Due to excess secretion of parathyroid hormone (PTH)

    • "Stones, bones, abdominal groans, psychic moans, and fatigue overtones"

    • Some patients are asymptomatic

    • Most common cause of hypercalcemia in the ambulatory patient

    • Nonparathyroid cancer is the most common cause of hypercalcemia in the hospitalized patient

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Epidemiology

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  • • 0.1-0.3% of the general population

    • 83% from single parathyroid adenoma, 6% from multiple adenomas, 10% from 4-gland hyperplasia, 1% from parathyroid carcinoma

    • Uncommon before puberty

    • Peak incidence is between third and fifth decade

    • 2-3 times more common in women than men

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Symptoms and Signs

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  • • Fatigue, weakness, arthralgias, nausea, vomiting, dyspepsia, constipation, polydipsia, polyuria, nocturia, psychiatric disturbances, renal colic, bone and joint pain

    • Nephrolithiasis and nephrocalcinosis, osteopenia, osteitis fibrosa cystica, peptic ulcer disease, gout, chondrocalcinosis, pancreatitis

    • Hypertension, band keratopathy

    • Neck mass (rare)

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Laboratory Findings

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  • • Elevated serum calcium

    • Elevated intact PTH level (although can be inappropriately high normal)

    • Elevated chloride; low or normal phosphate

    • Serum chloride to phosphate ratio of greater than 33

    • Uric acid and alkaline phosphatase sometimes elevated

    • Urine calcium increased or normal

    • Urine phosphate increased

    • Tubular reabsorption of phosphate decreased

    • Urine osteocalcin and deoxypyridinoline crosslinks increased

    Hydrocortisone suppression test: Reduces serum calcium in most cases of sarcoidosis and vitamin D intoxication but not primary hyperparathyroidism

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Imaging Findings

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  • • Subperiosteal resorption of radial side of phalanges

    • Demineralization of skeleton (osteopenia or osteoporosis)

    • Bone cysts

    • Nephrocalcinosis or nephrolithiasis

    • Neck sestamibi scan may localize adenomatous parathyroid gland

    • Neck US may localize an abnormally large parathyroid gland

    • Bone densitometry can document level of bone demineralization

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  • • Primary hyperparathyroidism also is part of the multiple endocrine neoplasia syndromes, type I and IIa

    • Other causes of hypercalcemia include:

    • -Hyperthyroidism

      -Addison disease

      -Pheochromocytoma

      -Hypothyroidism

      -VIPoma

      -Milk-alkali syndrome

      -Vitamin D or A overdose

      -Thiazides

      -Lithium

      -Aluminum

      -Granulomatous disease

      -Familial hypocalciuric hypercalcemia

      -Paget disease

      -Immobilization

      -Idiopathic hypercalcemia of infancy

      -Dysproteinemias

      -Rhabdomyolysis

    • Nonparathyroid tumors that secrete pure PTH are extremely rare

    • In patients with previous neck explorations, and negative preoperative localization studies (sestamibi/US), selective venous catheterization with PTH assay is recommended and helps localize tumors in about 80% of patients

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Rule Out

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  • • Parathyroid carcinoma (usually intraoperative discovery)

    • Ectopic hyperparathyroidism or nonparathyroid cancer

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  • • Complete history and physical exam

    • Serum calcium, PTH, phosphate, chloride, alkaline phosphatase, creatinine, blood urea nitrogen, urinary calcium

    • Cervical localization study (sestamibi with or without US)

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When to Admit

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  • • Hypercalcemic crisis:

    • -Patients need to be hydrated and have hypokalemia and hyponatremia corrected

      -Furosemide can increase calcium excretion in rehydrated patients

      -Glucocorticoids are effective in sarcoid, vitamin D intoxication, and cancer

      -Etidronate, plicamycin, and calcitonin are effective in lowering calcium level for short ...

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