Review: Primary Hyperparathyroidism, an Update: Incidence, Etiology, Diagnosis, and Treatment

A single bisphosphonate infusion is associated with improved functional capacity in elderly subjects with primary hyperparathyroidism

BACKGROUND AND AIMS

Neuromuscular symptoms are frequent features of primary hyperparathyroidism in elderly patients. Whether these symptoms are related to concomitant disorders or to hypercalcemia is of major importance in selecting patients who could benefit by parathyroidectomy. To address this hypothesis, we investigated the effects of transient normalization of calcemia on functional capacity by the administration of a single infusion of the bone resorption inhibitors pamidronate or clodronate.

METHODS

Functional capacity was evaluated by the functional independence measure (FIM) in 25 patients aged 87.1+/-0.8 years (means+/-SEM) with primary hyperparathyroidism. Nine patients aged 88.4+/-1.1 with primary hyperparathyroidism, not receiving any bisphosphonate, were used as controls.

RESULTS

By inhibiting bone resorption, bisphosphonate administration caused transient normalization of calcemia, associated with improved FIM, at a significantly higher level than in untreated patients (+16.1+/-6.0 vs +4.2+/-3.2%, p<0.05).

CONCLUSIONS

If confirmed in a randomized prospective study, these results indicate that a single bisphosphonate infusion, with consecutive transient improvement of functional capacity in relation to plasma calcium normalization, could help in identifying elderly patients who would benefit by parathyroidectomy.

Life-Threatening Hypercalcemia Associated With Primary Hyperparathyroidism During Pregnancy: Case Report And Review Of Literature

OBJECTIVE

To report a case of life-threatening hypercalcemia attributable to primary hyperparathyroidism in a pregnant patient and discuss the management of severe hypercalcemia during pregnancy.

METHODS

We describe a 28-year-old pregnant woman who had life-threatening hypercalcemia (serum calcium level of 25.8 mg/dL). Primary hyperparathyroidism was diagnosed. The patient's management and the published medical literature on primary hyperparathyroidism during pregnancy are reviewed.

RESULTS

Our patient had the highest reported serum calcium level that we could find attributable to primary hyperparathyroidism during pregnancy. After initial stabilization, parathyroidectomy was successfully performed during pregnancy. To our knowledge, this is the first report in which this profound degree of hypercalcemia did not result in an adverse maternal or fetal outcome.

CONCLUSION

Although uncommon, primary hyperparathyroidism during pregnancy may be associated with severe maternal and perinatal complications. Life-threatening hypercalcemia due to primary hyperparathyroidism during pregnancy can be successfully managed surgically during pregnancy, with good maternal and fetal outcome.

Serum ionized calcium, parathyroid hormone and related variables: effect of age and sex

This study was carried out in order to determine interrelationships of age and sex on parameters within the parathyroid endocrine system in healthy men and women. One hundred and fifteen normal subjects (70 females and 45 males) subdivided into three groups aged 25-35, 45-55 and 65-75 years were studied. Female subjects aged between 45 and 55 were further subdivided into two age-matched groups in relation to gonadal functional status. Serum intact parathyroid hormone (PTH) concentrations were measured using a two-site immunoradiometric assay. We found that there was a significant decrease of serum ionized calcium with ageing only in men (r = -0.666, P < 0.001) and a significant increase of serum PTH with age in both men (r = 0.488, P < 0.001) and women (r = 0.279, P < 0.019). A significant inverse correlation was found between serum ionized calcium and PTH in male subjects (r = -0.661, P < 0.001) and in fertile females (r = -0.353, P < 0.037) but not in postmenopausal women or in the entire female population. Furthermore, we found a significant decline of serum phosphate (r = -0.484, P < 0.001) and TmP/GFR (r = -0.492, P < 0.001) with advancing age in men, but not in women. We believe that the decrease of serum ionized calcium, as a likely consequence of the physiological reduction of intestinal calcium absorption, is the pivotal factor responsible for the increased PTH levels we observed with advancing age. The phenomenon is clear in men and in premenopausal women, but is masked in the female sex at menopause by the effects of a shortage of oestrogen on the calcium-phosphorus metabolism. These may also be responsible for the differences observed between the two sexes as far as phosphate metabolism is concerned. In conclusion, this study has, for the first time, taken relationships between serum ionized calcium and PTH, over a wide age range, into consideration. The results obtained show a marked difference of serum ionized calcium values between sexes with ageing, while serum parathyroid hormone levels increase in both men and women. Important differences also exist, as far as phosphate metabolism is concerned, between males and females.

Treatment of Severe Hypercalcemia in Primary Hyperparathyroidism with Aminopropylidene Diphosphonate

Objective:

To test the clinical usefulness and potency for decreasing plasma calcium concentration of an intravenously administered diphosphonate (aminopropylide diphosphonate [APD]) in a patient with hypercalcemic crisis secondary to primary hyperparathyroidism, unresponsive to hydration and furosemide, and who was ineligible for surgery because of cardiac conduction defects.

Design:

Case report.

Setting:

Referred care setting.

Intervention:

The patient received APD 15 mg/d, dissolved in 100 mL of isotonic NaCl 0.9% and infused in one hour.

Main Outcome Measure:

Plasma calcium concentration.

Results:

The patient's plasma calcium concentration fell considerably in a few days. The concomitant decrease in urinary calcium excretion indicates that this fall is caused by a decreased entry of calcium to the extracellular fluid and not to increased renal calcium excretion. After nine days, a parathyroid adenoma was removed; plasma calcium concentration remained normal during the following three years.

Conclusions:

APD is a useful adjunct to medical therapy in patients with hypercalcemic crisis secondary to primary hyperparathyroidism.