Presence of spondyloarthropathy and its clinical profile in patients with hypoparathyroidism

Hypoparathyroidism: Musculoskeletal Manifestations Related to Parathormone Deficiency

BACKGROUND

Hypoparathyroidism is a rare metabolic disorder that can be responsible for musculoskeletal manifestations.

AIM

We present a systematic review of musculoskeletal manifestations of adult-onset nonsurgical nongenetic hypoparathyroidism.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the MEDLINE database, including manuscripts describing musculoskeletal manifestations of adult-onset nonsurgical nongenetic hypoparathyroidism.

RESULTS

Musculoskeletal manifestations included myopathy, shoulder disorder, immune-negative non-erosive peripheral arthritis, axial involvement simulating spondylarthritis, and diffuse ligamentous ossifications. An association between hypoparathyroidism and spondyloarthritis or autoimmune diseases is possible. T-cell activation, seen in patients with hypoparathyroidism, may explain the co-occurrence of hypoparathyroidism with other autoimmune diseases. The treatment of these manifestations is based on calcium and active vitamin D supplementation. Parathyroid hormone may have an anabolic effect on muscle atrophy and muscle weakness. Parathyroid hormone can also promote bone formation and bone resorption by stimulating osteoclast differentiation by increasing RANKL (receptor activator for nuclear factor kappa-B ligand) expression. Therefore, hypoparathyroidism can be responsible for an increase in bone mineral density. However, the risk of fractures does not appear to be reduced due to changes in bone microarchitecture and the high risk of falls. Treatment with parathyroid hormone has been shown to improve bone microarchitecture.

CONCLUSION

Our review showed that musculoskeletal manifestations are frequent in patients with hypoparathyroidism, including muscular, axial, peripheral articular, and entheseal manifestations.

Coronary artery disease and its vascular associates in patients with chronic nonsurgical hypoparathyroidism

OBJECTIVE

Patients with chronic hypoparathyroidism (cHypoPT) are prone to intracranial-calcification, cataract and nephrocalcinosis. In this study, we systematically investigated the possibility of increased coronary artery calcification (CAC) and coronary artery disease (CAD) in them.

DESIGN

Cross-sectional.

PATIENTS AND MEASUREMENTS

Ninety-four nonsurgical cHypoPT (M:F = 50:44; age = 45 ± 15 years) with 18.6 ± 9.3 years of illness were assessed. Those with dyspnoea, angina, syncope, abnormal electrocardiogram, echocardiography or significant CAC underwent coronary angiography or myocardial-perfusion-stress imaging. Their lipid parameters and high-sensitivity C-reactive protein (hsCRP) were compared with age-matched healthy controls (Group A, n = 101). The prevalence of CAC in cHypoPT was compared with that of subjects referred from cardiology-clinics (Group B, n = 148, age = 52 ± 11 years).

RESULTS

One of 94 cHypoPT had known CAD. On screening, 17 cHypoPT required evaluation for CAD. Two of 17 had severe coronary stenosis, and 12 showed subclinical CAD. CAC and aortic-valve calcification occurred in 21.5% and 11.8%. Clinical and subclinical CAD, CAC and aortic-valve calcification in cHypoPT ≥50 years of age was 8.1%, 27.0%, 52.8% and 27.8%, respectively. Frequency of age-adjusted CAC was comparable between cHypoPT and control Group B (30.2% vs. 30.7%, p = .93). Elevated hsCRP was higher in cHypoPT than in controls A (52% vs. 32%, p < .01). Factors associated with CAD in cHypoPT were CAC and hypertension. However, CAD and CAC showed no association with long-term calcemic or phosphatemic control and intracranial-calcification in cHypoPT.

CONCLUSIONS

Clinical and subclinical CAD was observed in 3.2% and 12.8% of cHypoPT patients. The increased prevalence of CAD, CAC and aortic-valve calcification in cHypoPT above 50 years of age suggested their careful cardiac evaluation during follow-up.

Complications, Symptoms, Presurgical Predictors in Patients With Chronic Hypoparathyroidism: A Systematic Review

The complications and symptoms of hypoparathyroidism remain incompletely defined. Measuring serum parathyroid hormone (PTH) and calcium levels early after total thyroidectomy may predict the development of chronic hypoparathyroidism. The study aimed (i) to identify symptoms and complications associated with chronic hypoparathyroidism and determine the prevalence of those symptoms and complications (Part I), and (ii) to examine the utility of early postoperative measurements of PTH and calcium in predicting chronic hypoparathyroidism (Part II). We searched Medline, Medline In-Process, EMBASE, and Cochrane CENTRAL to identify complications and symptoms associated with chronic hypoparathyroidism. We used two predefined criteria (at least three studies reported the complication and symptom and had statistically significantly greater pooled relative estimates). To estimate prevalence, we used the median and interquartile range (IQR) of the studies reporting complications and symptoms. For testing the predictive values of early postoperative measurements of PTH and calcium, we used a bivariate model to perform diagnostic test meta-analysis. In Part I, the 93 eligible studies enrolled a total of 18,973 patients and reported on 170 complications and symptoms. We identified nine most common complications or symptoms probably associated with chronic hypoparathyroidism. The complications or symptoms and the prevalence are as follows: nephrocalcinosis/nephrolithiasis (median prevalence among all studies 15%), renal insufficiency (12%), cataract (17%), seizures (11%), arrhythmia (7%), ischemic heart disease (7%), depression (9%), infection (11%), and all-cause mortality (6%). In Part II, 18 studies with 4325 patients proved eligible. For PTH measurement, regarding the posttest probability, PTH values above 10 pg/mL 12-24 hours postsurgery virtually exclude chronic hypoparathyroidism irrespective of pretest probability (100%). When PTH values are below 10 pg/mL, posttest probabilities range from 3% to 64%. Nine complications and symptoms are probably associated with chronic hypoparathyroidism. A PTH value above a threshold of 10 pg/mL 12-24 hours after total thyroidectomy is a strong predictor that the patients will not develop chronic hypoparathyroidism. Patients with PTH values below the threshold need careful monitoring as some will develop chronic hypoparathyroidism. © 2022 American Society for Bone and Mineral Research (ASBMR).

Axial Spondyloarthritis: Mimics and Pitfalls of Imaging Assessment

Axial spondyloarthritis (axSpA) is a chronic inflammatory disorder that predominantly involves the axial skeleton. Imaging findings of axSpA can be divided into active changes, which include bone marrow edema, synovitis, enthesitis, capsulitis, and intra-articular effusion, and structural changes, which include erosions, sclerosis, bone fatty infiltration, fat deposition in an erosion cavity, and bone bridging or ankylosis. The ability to distinguish between imaging lesions suggestive of axSpA and artifacts or lesions suggestive of other disorders is critical for the accurate diagnosis of axSpA. Diagnosis may be challenging, particularly in early-stage disease and magnetic resonance imaging (MRI) plays a key role in the detection of subtle or inflammatory changes. MRI also allows the detection of structural changes in the subchondral bone marrow that are not visible on conventional radiography and is of prognostic and monitoring value. However, bone structural changes are more accurately depicted using computed tomography. Conventional radiography, on the other hand, has limitations, but it is easily accessible and may provide insight on gross changes as well as rule out other pathological features of the axial skeleton. This review outlines the imaging evaluation of axSpA with a focus on imaging mimics and potential pitfalls when assessing the axial skeleton.

Primary Hypoparathyroidism Mimicking Ankylosing Spondylitis in a Young Man with Fahr's Syndrome: A Case Report

Patients with chronic idiopathic hypoparathyroidism may develop neurological complications, including calcification of the basal ganglia and other areas of the brain. In Fahr's syndrome, intracranial calcification is associated with an underlying disorder such as hypo or hyperparathyroidism. We report the case of a 37-year-old gentleman, with a history of bilateral cataract surgery and seizures, who presented with a new episode of seizure and was found to have severe hypocalcemia and bilateral symmetric intracranial calcification due to previously diagnosed primary hypoparathyroidism. He had symptoms and signs mimicking ankylosing spondylitis (AS), but with negative radiological and serological findings, not fitting into the diagnosis of axial spondyloarthropathies (SpA), as per standard criteria. Patients with long-standing idiopathic hypoparathyroidism can have severe calcification of soft tissues and bones, including vertebrae and paravertebral soft tissues, causing inflammatory back pain and stiffness. It is vital to report such cases as their occurrence is rare, and physicians should be aware of the possibility while evaluating patients with inflammatory back pain. Treatment in these cases is directed towards hypocalcemia and underlying primary pathology rather than spondyloarthropathy.

A rare case of spondyloarthropathy: Iatrogenic hypoparathyroidism

Hypoparathyroidism is an endocrinopathy that can develop idiopathically, as well as due to reasons associated with genetics, autoimmunity, surgery and radiotherapy. It usually presents with neuromuscular signs and symptoms, including enthesopathy caused by calcification of the ligament and enthesis sites, soft tissue calcification, hypertension, cataract and extrapyramidal findings due to basal ganglia calcification. Hypoparathyroidism-associated spondyloarthropathy (SpA) is a rarely seen clinical entity. Hypoparathyroidism-associated SpA differs from other inflammatory SpAs in that the results for human leukocyte antigen B27 and inflammatory markers are negative and bone density is normal. The symptoms are relieved by calcium and vitamin D, rather than anti-inflammatory drugs. Due to this difference in treatment modalities, the diagnosis of this type of SpA is important. This article presents the case report of a 52-year-old female patient with iatrogenic hypoparathyroidism accompanied by asymptomatic hypocalcemia and SpA clinic.

Radiological Features of Long-Standing Hypoparathyroidism

BACKGROUND

Idiopathic hypoparathyroidism is an extremely rare endocrinal disorder with a prevalence of 37 per 100,000. Herein we presented a case of a 30-year-old male who came with symptoms of muscle weakness, carpopedal spasms and limitation of movement which gradually progressed over 8 years.

CASE REPORT

A 30-year-old male patient presented in an outpatient department of a tertiary care centre with a complaint of severe pain in both hip joints. He had generalized muscle weakness, facial discomfort, recurrent episodes of carpopedal spasms and crampy abdominal pains. On clinical examination, the patient had Chvostek sign and Trousseau sign. Biochemical tests revealed hypocalcemia, hyperphosphatemia and hypomagnesemia with low plasma parathyroid hormone level. X-ray of the pelvis and spine revealed spondylarthropathic changes of long-standing hypoparathyroidism. Computed Tomography of the brain revealed bilateral basal ganglia calcifications. The patient was treated with intravenous calcium gluconate, magnesium and oral vitamin D3. On follow-up the patient showed improvement of muscle weakness and carpopedal spasm with near-normal biochemical parameters. However, there was no improvement in symptoms related to spondyloarthropathy.

CONCLUSIONS

Idiopathic hypoparathyroidism is a rare endocrine disorder with clinic and biochemical features of hypocalcemia. Long- standing hypoparathyroidism can cause spondyloarthropathic changes closely resembling ankylosing spondylitis and DISH. Skeletal changes of long-standing hypoparathyroidism are irreversible. If left untreated, life-threatening complications like cardiac arrhythmias and broncholaryngospasm may occur.

Spondyloarthropathy occurring in long-standing idiopathic hypoparathyroidism

Idiopathic hypoparathyroidism can rarely present with extensive spondyloarthropathic changes that closely resemble ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, or fluorosis. Clinical presentation of the patient, typical laboratory parameters, and radiological findings aid in their differential diagnosis. Extensive spondyloarthropathy with normal sacroiliac joints in patients with neuromuscular symptoms like tetany, paresthesia, and hypocalcemia should raise the possibility of this entity.

Longstanding hypoparathyroidism in a fifty-two-year-old woman misdiagnosed as spondyloarthropathy

Introduction:

Hypoparathyroidism might cause various musculoskeletal findings, resembling Spondyloarthropathies.

Case Presentation:

We described a 52-year-old woman, diagnosed as a case of undifferentiated spondyloarthropathy for ten years, who was unresponsive to classic anti-inflammatory therapies. She developed anterior ischemic optic neuropathy and had elevated muscle enzymes during the course of disease. On a routine checkup, marked hypocalcemia and suppressed parathyroid hormone levels were found. Calcium and calcitriol therapy led to clinical and laboratory improvement.

Conclusions:

This case emphasizes the importance of recognizing rheumatic manifestations of hypoparathyroidism to preclude unnecessary treatments. Serum calcium should be included in the diagnostic workup of these patients.

Menstruation associated hypocalcemic symptoms and serum calcium in patients with idiopathic hypoparathyroidism

BACKGROUND

Some of the patients with idiopathic hypoparathyroidism (IHP) report symptoms of hypocalcemia during menstruation. There is limited data on this observation.

METHODS

Twenty six menstruating women with IHP and 26 healthy controls were questioned regarding symptoms suggestive of hypocalcemia during menstruation. Twelve patients and eight controls were asked to prospectively monitor symptoms suggestive of hypocalcemia and premenstrual syndrome (PMS) if any, over two consecutive menstrual cycles. Serum ionized calcium (SiCa++), total and albumin adjusted calcium and intact paratharmone (iPTH) were measured at eight points covering menstrual, immediate post-menstrual, mid-cycle and premenstrual phase.

RESULTS

Twelve of the 26 (46.2%) patients with IHP reported hypocalcemic symptoms during menstruation as compared to none of the controls. During prospective monitoring, there was no specific trend of hypocalcemic symptoms with respect to the phase of menstrual cycle. The mean SiCa++, serum total and albumin-adjusted calcium, iPTH and inorganic-phosphorus measured over two menstrual cycles were not significantly different in either of the two study groups. None of the subjects had PMS.

CONCLUSION

Women with IHP do not show any trend of hypocalcemic symptoms or fluctuations in serum calcium over different phases of menstrual cycles. Therefore, patients with hypoparathyroidism linking hypocalcemic symptoms with menstruation should be reassured regarding lack of this association.

Uncommon case of ankylosing spondylitis associated with spontaneous occurring hypoparathyroidism

Hypoparathyroidism and ankylosing spondylitis are two conditions with distinctive features which allow their differentiation. Hypoparathyroidism can be responsible for clinical and radiological changes resembling those seen in patients with ankylosing spondylitis. We report an exceptional case of a patient with an association between ankylosing spondylitis and a severe idiopathic hypoparathyroidism with difficulties in diagnosis. To our knowledge, this is the first case of such an occurrence.