Normal Parathyroid Hormone Levels Research Articles

Standards of care for hypoparathyroidism in adults: a Canadian and International Consensus.

Purpose: To provide practice recommendations for the diagnosis and management of hypoparathyroidism in adults. Methods: Key questions pertaining to the diagnosis and management of hypoparathyroidism were addressed following a literature review. We searched PubMed, MEDLINE, EMBASE and Cochrane databases from January 2000 to March 2018 using keywords ‘hypoparathyroidism, diagnosis, treatment, calcium, PTH, calcidiol, calcitriol, hydrochlorothiazide and pregnancy’. Only English language papers involving humans were included. We excluded letters, reviews and editorials. The quality of evidence was evaluated based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. These standards of care for hypoparathyroidism have been endorsed by the Canadian Society of Endocrinology and Metabolism. Results: Hypoparathyroidism is a rare disease characterized by hypocalcemia, hyperphosphatemia and a low or inappropriately normal serum parathyroid hormone level (PTH). The majority of cases are post-surgical (75%) with nonsurgical causes accounting for the remaining 25% of cases. A careful review is required to determine the etiology of the hypoparathyroidism in individuals with nonsurgical disease. Hypoparathyroidism is associated with significant morbidity and poor quality of life. Treatment requires close monitoring as well as patient education. Conventional therapy with calcium supplements and active vitamin D analogs is effective in improving serum calcium as well as in controlling the symptoms of hypocalcemia. PTH replacement is of value in lowering the doses of calcium and active vitamin D analogs required and may be of value in lowering long-term complications of hypoparathyroidism. This manuscript addresses acute and chronic management of hypoparathyroidism in adults. Main conclusions: Hypoparathyroidism requires careful evaluation and pharmacologic intervention in order to improve serum calcium and control the symptoms of hypocalcemia. Frequent laboratory monitoring of the biochemical profile and patient education is essential to achieving optimal control of serum calcium.

Parathyroid Gland Response to Vitamin D Deficiency in Type 2 Diabetes Mellitus: An Observational Study.

BackgroundStudies have linked vitamin D deficiency with the risk of type 2 diabetes mellitus (T2DM) and to the development of chronic complication of diabetes. Vitamin D receptors (VDR) have been found in many tissues in the body including the pancreas, a finding that indicates its role in insulin secretion. In addition, many studies have demonstrated the role of vitamin D and its receptor in insulin sensitivity and signal transduction. Vitamin D deficiency is common throughout the world, but not all vitamin D deficiencies are accompanied by a rise in parathyroid hormone (PTH). The present study was conducted to assess vitamin D deficiency in type 2 diabetic patients in comparison to healthy control and to determine parathyroid gland response to vitamin D deficiency in both groups.MethodsThis observational study was performed during a period from January to October 2018. The study included 151 type 2 diabetic patients selected from three diabetes clinics and 43 age and sex-matched healthy subjects. Informed consent and clinical information were obtained from all participants before the study. Results of the laboratory analysis for serum 25-hydroxyvitamin D (25-OHD), PTH, calcium, and phosphorous were recorded. The data was analyzed using the statistical package for the social sciences (SPSS) Statistics 17.ResultsThe results showed low vitamin D concentration in both groups; however, there was no significant difference in vitamin D concentration between diabetic patients and the control patients. A high percentage of PTH level was found in severe vitamin D deficient diabetic patients and healthy controls. The higher percentage of diabetic and normal subjects with mild vitamin D deficiency had a normal PTH level. All healthy subjects with vitamin D insufficiency showed normal PTH concentration. About 10% of diabetic patients with severe vitamin D deficiency had a low PTH level.ConclusionThe population in our study was generally deficient in 25-OHD irrespective of diabetes mellitus, indicating a greater need for vitamin D supplementation. Not all vitamin D deficient patients have high PTH levels, a finding that supports the emergence of new criteria for vitamin D deficiency, diagnosis and treatment, and highlights the importance of testing PTH in this regard.

Atypical presentation of Pneumocystis jirovecii pneumonia in a patient with rheumatoid arthritis treated with tofacitinib: a case presentation

BackgroundWe report the case of a patient with rheumatoid arthritis (RA) treated with tofacitinib who developed severe Pneumocystis jirovecii pneumonia (PJP) with an atypical clinical presentation.Case presentationA 78-year old male patient with RA treated with tofacitinib, methotrexate (MTX) and low dose corticosteroids was admitted to the hospital with arthralgia and nausea. Laboratory findings revealed hypercalcemia with normal levels of parathyroid hormone (PTH) and elevated 1,25-(OH)2 vitamin D levels. A lung CT scan showed bilateral interstitial pneumonic infiltrates. PCR from bronchoalveloar lavage was positive for Pneumocystis jirovecii. Hypercalcemia resolved under PJP treatment and was – after exclusion of other possible causes – probably fungal associated.ConclusionDue to the increased risk of opportunistic infections in immunocompromised patients, the finding of hypercalcemia in conjunction with a pulmonary infection should raise high clinical suspicion of PJP.

Bone mass preservation with high-dose cholecalciferol and dietary calcium in HIV patients following antiretroviral therapy. Is it possible?

Objective: To evaluate whether treatment with 100,000 IU/month (equivalent to 3200 IU/day) of cholecalciferol and 1 g/day of dietary calcium supplementation in HIV patients following different cART regimens yields normal levels of vitamin D3 and PTH as well as whether changes in bone mineral density are clinically significant.Methods: Consecutive HIV patients following different cART regimens received 100,000 IU/month (equivalent to 3200 IU/day) of cholecalciferol and 1 g/day of dietary calcium supplementation. The participants underwent BMD assessment via dual energy X-ray absorptiometry of the spine and hip at baseline (T0) and after 24 months (T1). Levels of 25(OH) vitamin D3 and parathyroid hormone (PTH) were assessed at T0 and T1. Quantitative variables were assessed with a paired t-test, independent t-test or analysis of variance, as appropriate. A chi-squared analysis was used to assess the association between qualitative variables. A p-value <0.05 was considered significant. Patients were divided into three groups depending on the cART regimen.Results: A total of 79 patients were included (40 males, 51% and 39 females, 49%), with a mean age of 46.6 (SD ±11.2) years, a baseline CD4 count of 649 cells/µl and a mean 25 hydroxycholecalciferol (25(OH) D3) value of 25 + 10 ng/ml. After 24 months, the 25(OH) D3 increased to 40 + 11 ng/ml. The initial BMDs at T0 were estimated as 0.919 (±0.27) and 0.867 (±0.14) g/cm2 at the spine and hip, respectively. After 24 months, the BMD was 0.933 (±0.15) g/cm2 at the spine and 0.857 (±0.14) g/cm2 at the hip. Based on a BMD change exceeding 3%, a worsening was observed in 23% of patients at the spine and 27% at the hip, whereas stability or improvement was demonstrated in 77% of patients at the spine and 73% at the hip.Subgrouping patients based on antiretroviral therapy indicated that, at T1, there was a statistically significant increase in vitamin D3 concentration in all patients, while PTH concentration was not significantly reduced in patients taking tenofovir or efavirenz. BMD stability or improvement was demonstrated in 77% of patients at the spine and 73% at the hip after 24 months.The multivariate analysis confirms a decrease in vitamin D3 and an increase in PTH levels in smokers, as well higher vitamin D3 concentrations in males and lower spine BMDs in menopausal females.Conclusion: The proposed protocol of cholecalciferol and dietary calcium supplementation is safe and valid for correcting vitamin D abnormalities in almost all patients as well as reducing PTH levels in a high percentage of patients; however, it is not sufficient for normalization, particularly in patients exposed to tenofovir or efavirenz. At the spine, no significant BMD change was found in any of the therapy groups. At the hip, our data confirm a modest negative effect on bone mass caused by tenofovir and efavirenz.

Clinical features and tubulin folding cofactor E gene analysis in Iranian patients with Sanjad–Sakati syndrome

ObjectivePermanent hypoparathyroidism can be presented as part of genetic disorders such as Sanjad–Sakati syndrome (also known as hypoparathyroidism—intellectual disability-dysmorphism), which is a rare autosomal recessive disorder. Our aim was to confirm the diagnosis of a group of patients with dysmorphism, poor growth, and hypoparathyroidism clinically labeled as Sanjad–Sakati syndrome and to identify for the first time the genetic variations on Iranian patients with the same ethnic origin. MethodsIn this study, 29 cases from 23 unrelated Arab kindreds with permanent hypoparathyroidism and dysmorphism indicating Sanjad-Sakati syndrome were enrolled for 10 years in the southwest of Iran. The mutational analysis by direct sequencing of the tubulin folding cofactor E gene was performed for the patients and their families, as well as their fetuses using genomic DNA. ResultsTwenty-eight out of 29 cases had parental consanguinity. Twenty-seven cases presented with hypocalcemia seizure and two were referred because of poor weight gain and were found to have asymptomatic hypocalcemia. The dysmorphic features, hypocalcemia in the setting of low to normal parathyroid hormone levels and high phosphorus led to the diagnosis of these cases. Sequencing analysis of the tubulin folding cofactor E gene revealed a homozygous 12-bp deletion (c.155–166del) for all patients. Following that, prenatal diagnosis was performed for eight families, and two fetuses with a homozygous 12-bp deletion were identified. ConclusionThese results make it much easier and faster to diagnose this syndrome from other similar dysmorphisms and also help to detect carriers, as well as prenatal diagnosis of Sanjad-Sakati syndrome in high-risk families in this population.

Generation of 1,25-dihydroxyvitamin D3 in Cyp27b1 knockout mice by treatment with 25-hydroxyvitamin D3 rescued their rachitic phenotypes

We have reported that 25-hydroxyvitamin D3 [25(OH)D3] binds to vitamin D receptor and exhibits several biological functions directly in vitro. To evaluate the direct effect of 25(OH)D3 in vivo, we used Cyp27b1 knockout (KO) mice, which had no detectable plasma 1α,25-dihydroxyvitamin D3 [1,25(OH)2D3] when fed a diet containing normal Ca and vitamin D. Daily treatment with 25(OH)D3 at 250 μg kg-1 day-1 rescued rachitic phenotypes in the Cyp27b1 KO mice. Bone mineral density, female sexual cycles, and plasma levels of Ca, P, and PTH were all normalized following 25(OH)D3 administration. An elevated Cyp24a1 mRNA expression was observed in the kidneys, and plasma concentrations of Cyp24a1-dependent metabolites of 25(OH)D3 were increased. To our surprise, 1,25(OH)2D3 was detected at a normal level in the plasma of Cyp27b1 KO mice. The F1 to F4 generations of Cyp27b1 KO mice fed 25(OH)D3 showed normal growth, normal plasma levels of Ca, P, and parathyroid hormone, and normal bone mineral density. The curative effect of 25(OH)D3 was considered to depend on the de novo synthesis of 1,25(OH)2D3 in the Cyp27b1 KO mice. This suggests that another enzyme than Cyp27b1 is present for the 1,25(OH)2D3 synthesis. Interestingly, the liver mitochondrial fraction prepared from Cyp27b1 KO mice converted 25(OH)D3 to 1,25(OH)2D3. The most probable candidate is Cyp27a1. Our findings suggest that 25(OH)D3 may be useful for the treatment and prevention of osteoporosis for patients with chronic kidney disease.

A retrospective analysis of treatment of wounds caused by calciphylaxis: Hyperbaric oxygen therapy with and without sodium thiosulfate

Calciphylaxis, or calcific uremic arteriolopathy, is a rare, but devastating condition with a mortality approaching 80% in the United States, often seen in patients with chronic kidney disease. It is characterized by calcification and intimal fibrosis with arteriolar stenosis and subsequent thrombosis. Skin changes such as livedo reticularis, tender papules, and violaceous plaques result and progress to necrotic ulceration. Management of calciphylaxis includes maintenance of normal levels of calcium, phosphorus and parathyroid hormone, and optimization of hemodialysis and nutritional status. In our cohort, aggressive wound management coupled with sodium thiosulfate and hyperbaric oxygen therapy (HBOT) has achieved improvement in rates of healing for recalcitrant wounds associated with calciphylaxis but limited evidence for the efficacy of either treatment exists. We conducted a retrospective analysis of 94 patients treated for calciphylaxis at a Wound and Hyperbaric Center at an academic institution between 2000 and 2017 who were considered for HBOT. We assessed whether response to therapy as measured by wound healing varied among patients who received sodium thiosulfate, hyperbaric oxygen treatment, both therapies, or neither therapy. We found HBOT to be beneficial in healing compared to no therapy - 81.7% or 36 of 44 patients with complete or substantial resolution of their wounds vs. neither therapy - 11.4% or 3 of 26 patients. We found sodium thiosulfate to be beneficial in healing compared to neither therapy - 66.6% or 2 of 3 patients with complete or substantial resolution of their wounds vs. no therapy. We found combined HBOT & sodium thiosulfate to be more beneficial in healing compared to either therapy alone and to neither therapy - 86.3% or 19 of 22 patients with complete or substantial resolution of wounds. Given the dramatic clinical improvement, HBOT in combination with sodium thiosulfate has an important adjunctive role in the treatment of calciphylaxis.

Bone metabolism, density, and geometry in postmenopausal women with vitamin D insufficiency: a cross-sectional comparison of the effects of elevated parathyroid levels.

In vitamin D insufficiency, elevated parathyroid hormone (PTH) levels may contribute to adverse effect on bone. We assessed effects of PTH responses to vitamin D insufficiency on bone metabolism, density, and geometry. Using a cross-sectional design, we investigated 102 healthy postmenopausal women with low 25-hydroxy-vitamin D (< 50nmol/L) levels, who had either secondary hyperparathyroidism with elevated PTH levels (> 6.9pmol/L, N = 51) or normal PTH levels (N = 51). Bone mineral density (BMD) and bone geometry were assessed by Dual-Energy X-ray absorptiometry (DXA), quantitative computed tomography (QCT) and high-resolution peripheral QCT (HRpQCT) scans. Bone metabolism was assessed by biochemistry including bone turnover markers. Levels of 25(OH)D were 38 (IQR 31-45) nmol/L with no differences between groups. PTH levels were 8.5 (IQR 7.5-9.5) in women with SHPT and 5.2 (4.4-6.6) pmol/L in women with normal PTH (p < 0.001). BMI and eGFR did not differ between groups. SHPT was associated with lower total- and trabecular bone area, lower cortical perimeter, and increased cortical area in tibia and radius. SHPT was associated with a lower weight-adjusted BMD at the lumbar spine (p < 0.05). High compared to normal PTH levels were associated with significantly lower plasma levels of 1,25(OH)2D, phosphate, but higher levels of osteocalcin and borderline higher levels of CTx. PTH correlated to osteocalcin and CTx. High PTH levels are associated with altered bone geometry, increased bone turnover, and reduced BMD at the spine. Whether an increased cortical thickness with a lower trabecular volume is an effect of PTH or not needs further elucidations.

Vitamin D Deficiency and Evaluation of the Parathyroid Hormone Status in People Living with HIV in Côte d’Ivoire

Background: Micronutrients play an important role in the human immune system. During HIV infection, the virus utilises the micronutrients of the body, for its replication causing metabolic disorders including phosphocalcic. Parathyroid hormone (PTH), vitamin D3 (25-hydroxyvitamin D3) and calcitonin are essential for the maintenance of phosphocalcic homeostasis and the proper functioning of the body. In Côte d'Ivoire, very few studies on HIV infection and the mechanism of phosphocalcic metabolism have been done. The purpose of this study was to determine the status of 25 (OH) D3 and parathyroid hormone in people living with HIV.&#x0D; Methodology: The study involved 326 adults (163 HIV-positive and 163 HIV-negative as control subjects). After confirmation by HIV serologic scanning result, CD4 count was performed by flow cytometry (Facs Calibur). Assays for 25 (OH) D3 and PTH were performed by HPLC and COBAS 6000 automated systems, respectively.&#x0D; Results: A decrease in mean values ​​of 25 (OH) D3 (16 ± 0.46 ng / mL) was observed in 50% of HIV-infected on ART and 87% of these patients presented a normal PTH level (28 ± 1.95 pg / mL). Deficiency of 25 (OH) D3 (20 ± 1.03 ng / mL) is higher in HIV-infected on ART who have a CD4 count &lt; 200 cells / mL.&#x0D; Conclusion: Parathyroid hormone levels were normal in this study. Insufficiency or deficiency of 25-hydroxyvitamin D3 is more common in HIV-infected on ART with a CD4 count &lt; 200 cells / mL. This decrease characterized the degree of immunodepression.

Discrepancy between the recommended and functional cut offs of Vitamin D among under-five children: Experiences from a pilot study

Background and Objectives:Vitamin D is a key determinant of bone health and calcium homeostasis in children. Vitamin D deficiency (VDD) in early years may have an effect on total bone mass and risk of osteoporosis. Despite widespread prevalence of VDD among children, there is limited information in under-five age group. The objectives of the current study were to estimate the community-based prevalence of VDD and to identify the factors associated with children aged 1–5 years.Materials and Methods:A community-based cross-sectional study was conducted among 201 apparently healthy children (aged 1–5 years) in an urban slum of the selected geographical area in Mumbai. VDD was defined as serum 25-hydroxy Vitamin D (25[OH]D) levels <20 ng/ml as per the US Endocrine society classification.Results:The prevalence of VDD was found to be 74.6% (95% of confidence interval [68.6–80.6]). It was significantly higher (P = 0.04) among children staying indoors (44.8%). 25(OH)D was negatively correlated with parathyroid hormone (PTH) ([r = −0.199, P = 0.005]) and Alkaline phosphatase ([r = −0.140, P = 0.05]). However, the increase in PTH was observed when 25(OH)D levels were <10 ng/ml unlike anticipated increase at <20 ng/ml.Conclusion:The study revealed a high prevalence of VDD in 1–5 years age group. It was observed that the outdoor activities and sun exposure have a significant association with Vitamin D status. Majority of children had normal PTH levels despite VDD. The study endorses the importance of sun exposure and throws light on that fact that functional cutoffs for VDD may be lower in under-five children and also highlights the need of redefining cutoffs of Vitamin D among the Indian children.

Novel Mutation in PTHLH Related to Brachydactyly Type E2 Initially Confused with Unclassical Pseudopseudohypoparathyroidism.

BackgroundAutosomal-dominant brachydactyly type E is a congenital abnormality characterized by small hands and feet, which is a consequence of shortened metacarpals and metatarsals. We recently encountered a young gentleman exhibiting shortening of 4th and 5th fingers and toes. Initially, we suspected him having pseudopseudohypoparathyroidism (PPHP) because of normal biochemical parameters, including electrolyte, Ca, P, and parathyroid hormone (PTH) levels; however, his mother and maternal grandmother had the same conditions in their hands and feet. Furthermore, his mother showed normal biochemical parameters. To the best of our knowledge, PPHP is inherited via a mutated paternal allele, owing to the paternal imprinting of GNAS (guanine nucleotide binding protein, alpha stimulating) in the renal proximal tubule. Therefore, we decided to further analyze the genetic background in this family.MethodsWhole exome sequencing was performed using genomic DNA from the affected mother, son, and the unaffected father as a negative control.ResultsWe selected the intersection between 45,490 variants from the mother and 45,646 variants from the son and excluded 27,512 overlapping variants identified from the father. By excluding homogenous and compound heterozygous variants and removing all previously reported variants, 147 variants were identified to be shared by the mother and son. Variants that had least proximities among species were excluded and finally 23 variants remained.ConclusionAmong them, we identified a defect in parathyroid hormone like hormone (PTHLH), encoding the PTH-related protein, to be disease-causative. Herein, we report a family affected with brachydactyly type E2 caused by a novel PTHLH mutation, which was confused with PPHP with unclassical genetic penetrance.

Evaluation of the Relationship between the Serum Alkaline Phosphatase Level at Dialysis Initiation and All-Cause Mortality: A Multicenter, Prospective Study

Background/Aim: High serum alkaline phosphatase (ALP) levels predict mortality independent of bone metabolism parameters and liver function test results in patients on hemodialysis. The relationship between serum ALP at dialysis initiation and mortality during maintenance dialysis is unknown; therefore, we aimed to identify an association. Methods: This multicenter, prospective cohort study analyzed 1,213 patients registered in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis from October 2011 to September 2013. Patients were divided into 2 groups based on serum ALP levels. All-cause mortality and incidences of cardiovascular events after dialysis initiation were compared using the log-rank test and multivariate Cox proportional hazard regression analysis. We performed stratified analysis based on parathyroid hormone (PTH) levels. Results: During the follow-up, 109 (18.0%) and 86 (14.1%) patients died in the high ALP group (232 ≥IU/L; High ALP group) and low ALP group (232 <IU/L; Low ALP group), respectively. All-cause mortality was significantly higher in the High ALP group than in the Low ALP group (p = 0.014). The serum ALP level was significantly correlated with the all-cause mortality rate (hazard ratio = 1.17 per 100 IU/L increase of ALP, 95% confidence interval: 1.11–1.24, p < 0.001). The all-cause mortality rate was significantly higher in the High ALP group among patients with low (<150 pg/mL) or normal (150–300 pg/mL) PTH levels (p = 0.012 and p = 0.005, respectively) than in the Low ALP group; there was no significant difference among patients with a high (≥300 pg/mL) PTH level (p = 1.000). Conclusion: The serum ALP level at dialysis initiation is associated with all-cause mortality during maintenance dialysis.

Surgery for Primary Hyperparathyroidism with Normal Non-suppressed Parathyroid Hormone can be Both Challenging and Successful.

Criteria for diagnosing primary hyperparathyroidism (PHPT) include hypercalcemia in the presence of parathyroid hormone (PTH) levels that are either elevated (classic PHPT) or normal but non-suppressed. However, there is no standard definition of what constitutes normal non-suppressed levels, and data are lacking regarding the potential for surgical cure in these patients. A retrospective review of patients undergoing parathyroidectomy for sporadic PHPT between 2012 and 2014 was performed. Patients with normal PTH were compared to classic PHPT patients to assess demographics, imaging, operative findings, and outcomes. In total, 332 patients met study criteria, and 60 (18%) had normal PTH levels. Negative sestamibi scans were seen more often with normal PTH levels (18.3 vs. 4.8%, p<0.001). Patients with normal PTH were more likely to have ≥2 glands removed (26.7 vs. 14.3%, p=0.02), and the specimens were more likely to be classified as only mildly hypercellular or normocellular (20 vs. 2.9%, p<0.001). Average follow-up was 24months (range 6-55). Cure rate was 88% in the normal PTH group, compared to 96% in classic PHPT (p=0.02). Among patients with normal PTH, those with PTH≤55pg/mL had an 83% cure rate, whereas those with PTH 56-65 had a 96% cure rate (p=0.12). Parathyroidectomy can have a high cure rate in the context of normal PTH levels despite an increased likelihood of negative imaging and multigland resection. Operative success is equivalent to classic PHPT when PTH levels are >55pg/mL.

Primary hyperparathyroidism.

In this Review, we describe the pathogenesis, diagnosis and management of primary hyperparathyroidism (PHPT), with a focus on recent advances in the field. PHPT is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic in regions of the world where serum levels of calcium are routinely measured. In addition to mild hypercalcaemia, PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Other clinical forms of PHPT, such as classical disease and normocalcaemic PHPT, are less common. Parathyroidectomy, the only curative treatment for PHPT, is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae. Parathyroidectomy results in an increase in BMD and a reduction in nephrolithiasis. Various medical therapies can increase BMD or reduce serum levels of calcium, but no single drug can do both. More data are needed regarding the neuropsychological manifestations of PHPT and the pathogenetic mechanisms leading to sporadic PHPT, as well as on risk factors for complications of the disorder. Future work that advances our knowledge in these areas will improve the management of the disorder.

The impact of vitamin D status on hungry bone syndrome after surgery for primary hyperparathyroidism.

Prolonged hypocalcemia but normal intact parathyroid hormone (iPTH) levels after surgery for primary hyperparathyroidism (PHPT) are referred to as 'hungry bone syndrome' (HBS). The aim was to evaluate preoperative risk factors for HBS with a focus on the impact of 25-hydroxyvitamin D (25(OH)D) deficiency. Patients having undergone initial successful surgery for sporadic PHPT within 6 years were considered for retrospective analysis. A total of 385 patients were evaluated, of whom 33 (8.6%) developed HBS influencing negatively the postoperative bone metabolism. All patients underwent biochemical evaluations two days before parathyroid surgery and were followed biochemically on a daily basis in the first postoperative week and thereafter at 8 weeks and 6 months. No relationship was established between preoperative 25(OH)D deficiency and HBS. The only significant risk factor for HBS in multivariable analysis was high levels of preoperative iPTH. As HBS therefore cannot be predicted preoperatively, we recommend a consistent postoperative calcium and vitamin D supplementation to improve the bone metabolism.

Reversible central neural hyperexcitability: an electroencephalographic clue to hypocalcaemia

A 23-year-old male patient presented with cognitive decline and seizures. Examination revealed Chvostek's and Trousseau's signs. Investigations revealed hypocalcaemia, hyperphosphatemia and normal intact parathyroid hormone levels. Imaging showed calcifications in...

Causes of elevated parathyroid hormone levels in postmenopausal women

Objective. In this study we aimed to investigate causes of hyperparathyroidism and related factors in postmenopausal women. Methods. The study was conducted on 156 postmenopausal women, 43 with normal serum parathyroid hormone (PTH) levels and 113 with elevated serum PTH levels. Serum levels of 25-OH vitamin D, calcium and phosphorus, 24-hour urine calcium, phosphorus and calcium/creatinine ratio were compared between study groups. Also, bone mineral density, age of menopause, educational level, occupation, clothing style, daylight exposure time and daily dietary calcium consumption of subjects and relationships of these parameters with parathyroid hormone levels were investigated. Results. Causes of elevated serum PTH level were vitamin D deficiency in 92.9% and primary hyperparathyroidism in 4.4% of study group. Serum PTH levels were significantly higher in housewives ( p <0.001), women with less than a high school graduates ( p =0.008), and the veiled women ( p =0.025). Serum 25-OH vitamin D levels were significantly lower in the veiled covered ( p =0.002) and participants with less than a high school graduate ( p =0.041). Significant negative correlation was detected between serum 25-OH vitamin D and the logarithmic value of serum PTH levels (r= -0.188; p =0.019). Conclusions. Vitamin D deficiency was common in all postmenopausal women but especially in those with lower education level and the veiled. Postmenopausal women should be screened for vitamin D deficiency and encouraged to benefit more from sunlight. Also, enriching foods in the markets with vitamin D may be helpful for decreasing hyperparathyroidism in this population.

Drug safety evaluation of parathyroid hormone for hypocalcemia in patients with hypoparathyroidism

ABSTRACTIntroduction: Hypoparathyroidism is a rare disorder characterized by low serum calcium levels and high serum phosphate levels, and low or inappropriately normal levels of parathyroid hormone (PTH). This disease is commonly treated with calcium supplements and active vitamin D metabolites or analogues, but large doses of these supplements are often utilized to relieve the symptoms caused by hypocalcemia, without guarantee of a physiological normalization of calcium-phosphate homeostasis.Areas covered: Several studies have investigated replacement therapy with recombinant human PTH [rhPTH (1-84) and rhPTH (1-34)] for subjects with hypoparathyroidism. In 2015, The Food and Drug Administration (FDA) approved, in the United States, rhPTH (1–84), named Natpara®, a bioenginerred rhPTH, for the management of chronic hypoparathyroidism not well controlled with conventional therapy. This article evaluates the safety and tolerability of rhPTH (1–84) in patients with chronic hypoparathyroidism, and also describes the studies conducted so far on rhPTH (1-34) used for chronic hypoparathyroidism.Expert opinion: The research done in this field has shown that replacement treatment with rhPTH is an attractive option for subjects with hypoparathyroidism who are unable to maintain stable and safe serum and urinary calcium levels. However, since therapy with rhPTH is a long-term management option in hypoparathyroidism, more long-term safety data are needed.

Acute lymphoblastic leukemia: primary bone manifestation with hypercalcemia in a child

Primary bone manifestation associated with hypercalcemia is an infrequent presentation of acute lymphoblastic leukemia (ALL) in children. An 8-year-old girl was admitted with bone and abdomen pain, vomiting, fever, headache, anemia, elevated serum calcium and normal parathyroid hormone levels. Bone radiographs: osteolytic lesions. Bone marrow biopsy showed an infiltration by ALL with immunohistochemical positivity for CD45, CD20, CD79a, TdT and CD10, clinically characterized by hypercalcemia, multifocal osteolytic lesions and single cytopenia. Bone marrow biopsy was a relevant aid in establishing the diagnosis of multifocal osteolytic lesions, associated with hypercalcemia.

Assessment of calcium homeostasis after total thyroidectomy in differentiated thyroid carcinoma

Background: After total thyroidectomy, hypocalcaemia can be transient or permanent. Most of the patients are being prescribed long term calcium supplementation despite preserving parathyroid glands. We have tried to study the various calcium homeostatic factors to predict the long term calcium levels in differentiated thyroid carcinoma following total thyroidectomy. Method: Study was conducted in a tertiary care centre and a total number of 28 patients of differentiated thyroid carcinoma were retrospectively analysed who underwent surgery from 2013 - 2015. Post surgery patients were given thyroxine and calcium supplementation with regular monitoring of thyroid function test and serum calcium. Serum Parathormone(PTH) levels were recorded after minimum of one year of completion of surgery. Results: Out of 28 patients, 26 patients have serum parathormone within normal range (15-65 pg/ml). Only two patients have low serum PTH values ( Conclusion: Our study reveals optimum calcium homeostasis in patients undergoing total thyroidectomy. A long term follow up of these patients is required so that many patients with normal PTH levels may not require calcium supplementation.