Hyperparathyroidism - primary

Question 1

What is the mnemonic for the signs and symptoms of hyperparathyroidism?

Answer 1

BONES, MOANS, GROANS AND STONES:

· Bones - pain, osteoporosis.
· Moans - depression, fatigue.
· Groans - myalgia.
· Stones - kidney stones.

Question 2

Who is most commonly affected?

Answer 2

Most commonly found in women aged between 50 and 60 (post-menopausal).

Question 3

What is the pathophysiology of hyperparathyroidism?

Answer 3

· Low serum calcium stimulates PTH secretion.
· High calcium levels suppress PTH secretion.
· In PHPT, PTH secretion is not suppressed by high calcium levels.
· Excessive PTH leads to:
- Over-stimulation of bone resorption.
- Over-stimulation of the kidneys to reabsorb calcium and convert it to its active form. This active vitamin D is responsible for the GI absorption of calcium.

Question 4

What is the aetiology of hyperparathyroidism?

Answer 4

· PHPT is caused by inappropriate secretion of PTH, leading to hypercalcaemia.
· The most common cause is a parathyroid adenoma.
· Inherited disease is in 10-20%, leading to hyperfunctioning parathyroid glands - MEN1/2/4.
· Less than 1% are due to parathyroid malignancies.
· External neck irradiation.
· Lithium use.

Question 5

List the most common risk factors.

Answer 5

· Female.
· Aged 50-60 years.
· FHx of PHPT.
· Multiple Endocrine Neoplasia (MEN) 1, 2A or 4.
· Current or historical lithium treatment.
· Hx of head and neck irradiation.

Question 6

Diagnosis requires which 4 investigations? What will the investigations typically show?

Answer 6

· Serum calcium - high-normal to raised.
· Serum phosphate - decreased.
· PTH level - increased.
· Normal or raised urinary

Question 7

Differentials?

Answer 7

· Familial hypocalciuric hypercalcaemia. 
· Humoral hypercalcaemia of malignancy. 
· Multiple myeloma. 
· Thyrotoxicosis. 
· Leukaemia.
· Thiazide use.

Question 8

What is the treatment option for a symptomatic OR asymptomatic patient with surgical indications?

Answer 8

· 1st line - Parathyroidectomy.
· Adjunct - Vitamin D supplementation.
· 2nd - Monitoring.
· Adjunct - Bisphosphonate.

Question 9

What is the treatment option for an asymptomatic patient with no surgical indications?

Answer 9

· 1st line - Monitoring.
· Adjunct - Vitamin D supplementation.
· 2nd - Parathyroidectomy.

Question 10

What complications may arise?

Answer 10

· Osteoporosis. 
· Bone fractures.
· Nephrolithiasis. 
· Pneumothorax following surgery. 
· Hypocalcaemia following surgery. 
· Recurrent and superior laryngeal nerve injury following surgery.