Hyperparathyroidism Flashcards

1
Q

Hyperparathyroidism is when there are high levels of parathyroid hormone in the circulation. There are 3 types of hyperparathyroidism, which of these is most common?

1 - tertiary
2 - secondary
3 - primary

A

3 - primary

Primary = tumour of parathyroid gland
Secondary = low vitamin D or CKD
Tertiary = Prolonged secondary leading to hyperplasia of parathyroid gland

85%: solitary adenoma
10%: hyperplasia
4%: multiple adenoma
1%: carcinoma

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2
Q

What is the incidence of primary hyperparathyroidism?

1 - 4000 cases per 100,000
2 - 400 cases per 100,000
3 - 40 cases per 100,000
4 - 4 cases per 100,000

A

3 - 40 cases per 100,000

More common in females 3:1 ratio

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3
Q

What age does the incidence of primary hyperparathyroidism peak at?

1 - 15-30
2 - 30-45
3 - 50-65
4 - >70

A

4 - >70

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4
Q

Which of the following is NOT a risk factor for primary hyperparathyroidism?

1 - Male sex
2 - Older age
3 - Family history
4 - all of the above

A

1 - Male sex

More common in females, 3:1 ratio

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5
Q

There are 4 parathyroid glands located on the back of the thyroid gland. Which cell in the parathyroid glands secretes parathyroid hormone?

1 - follicular cells
2 - chief cells
3 - parietal cells
4 - langerhans cells

A

2 - chief cells

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6
Q

When calcium is low in the blood parathyroid hormone is released in an attempt to increase calcium levels. Which of the following is NOT a key site where parathyroid hormone receptors can be found and contribute towards maintaining sufficient levels of calcium in the circulation?

1 - bone = binds osteoblasts and recruits osteoclasts for bone resorption
2 - kidney = reduces Ca2+ excretion
3 - lungs = increase ACE production
4 - GIT = increases Ca2+ in small intestines

A

3 - lungs = increase ACE production

Bone = osteoblasts activate osteoclasts that break down bone causing increased Ca+2 and phosphate in the blood

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7
Q

If a patient has hyperparathyroidism, they will experience hypercalcaemia as the negative feedback in the parathyroid is dysfunctional, so lots of parathyroid is released. Which of the following is NOT a typical clincal feature of hypercalcaemia?

1 - increased risk of kidney and gall bladder stones
2 - bone pain
3 - osteopenia and osteoporosis
4 - abdominal pain, constipation, nausea + vomiting
5 - psychotic overtones

A

1 - increased risk of kidney and gall bladder stones

Does increase kidney stones, but NOT gall bladder stones

Psychic overtones includes:
- Fatigue
- Depression
- Memory impairment

Patients may also present with polyuria, paresthesia and muscle cramps.

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8
Q

When trying to diagnose hyperparathyroidism, it is important to measure which 2 of the following together?

1 - U&Es
2 - adjusted Ca2+
3 - parathyroid hormone
4 - thyroid hormone

A

2 - adjusted Ca2+
3 - parathyroid hormone

In primary hyperparathyroidism BOTH will be high

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9
Q

What is the definition of hypercalcaemia when the serum Ca2+ has been adjusted?

1 - >2mmol/L
2 - >2.6mmol/L
3 - >3mmol/L
4 - >3.6mmol/L

A

2 - >2.6mmol/L

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10
Q

If a patient presents with symptoms of hypercalcaemia but the rise in Ca2+ is rapid, is this likely to be primary hyperparathyroidism?

A
  • No

Typically a slow disease occurring months to years

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11
Q

Which of the following tests would be useful to rule out non-parathyroid gland causes of hypercalcaemia?

1 - estimated glomerular filtration rate (eGFR) and creatinine (AKI or CKD)
2 - serum and urine protein electrophoresis, and urine Bence-Jones protein (myeloma)
3 - FBC to exclude haematological malignancy
4 - LFTs (liver metastasis/systematic diseases)
5 - DEXA (bone health and risk of osteopenia/osteoporosis)
6 - all of the above

A

6 - all of the above

Imaging may be used if malignancy is suspected

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12
Q

The most common differential for primary hyperparathyroidism is malignancy. Which 2 of the following are the most likely mechanisms?

1 - pituitary adenoma
2 - PTH-related-protein (PTHrP) secreting tumours
3 - Osteolytic lesions (e.g. bone metastasis and multiple myeloma)
4 - metastatic malignancy

A

2 - PTH-related-protein (PTHrP) secreting tumours
3 - Osteolytic lesions (e.g. bone metastasis and multiple myeloma)

Squamous cell carcinoma is common in lung cancer

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13
Q

In hypercalcaemia of malignancy is serum PTH high or low?

A
  • low
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14
Q

Which of the following would be present in secondary hyperparathyroidism?

A
  • high PTH to try and increase C2+
  • low/normal Ca2+ due to CKD and/or low vitamin D levels
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15
Q

Which of the following would be present in primary hyperparathyroidism?

A
  • high PTH due to tumour
  • high Ca2+ due to high PTH
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16
Q

Which of the following would be present in tertiary hyperparathyroidism?

A
  • high PTH due to parathyroid hyperplasia
  • high Ca2+ due to high PTH
17
Q

According to NICE, what is the typically treatment for primary hyperparathyroidism?

1 - bisphosphonates
2 - parathyroidectomy
3 - radiotherapy
4 - vitamin D supplements

A

2 - parathyroidectomy

98% cure rates

18
Q

Surgery is recommended for primary hyperparathyroidism if a patient has how many of the following?

  • symptoms of hypercalcaemia
  • osteoporosis and/or fragility fractures
  • renal stones or nephrocalcinosis
  • age <50 years
  • serum adjusted calcium >2.85 mmol/L
  • eGFR <60 mL/min/1.73 m²

1 - all of the above
2 - >4
3 - >3
4 - >1

A

4 - >1

1 or more with symptoms is an indicator for surgery

19
Q

What is typically the 1st line treatment for a patient with secondary hyperparathyroidism?

1 - bisphosphonates
2 - parathyroidectomy
3 - radiotherapy
4 - vitamin D supplements

A

4 - vitamin D supplements

Also need to treat the CKD

20
Q

What is typically the 1st line treatment for a patient with tertiary hyperparathyroidism?

1 - bisphosphonates
2 - parathyroidectomy
3 - radiotherapy
4 - vitamin D supplements

A

2 - parathyroidectomy

Removal of the hyperplastic tissue, but ensure sufficient PTH remains for normal function