• 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
• 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
• 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)
• 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
• 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
• Primary hyperparathyroidism also is part of the multiple endocrine neoplasia syndromes, type I and IIa
• Other causes of hypercalcemia include:
• 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
• 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)
• 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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