Serum Parathyroid Hormone Values Research Articles

Secondary hyperparathyroidism in chronic kidney disease: pathomechanism and current treatment possibilities.

Secondary hyperparathyroidism (SHPT) is one of the most common metabolic complications resulting from chronic kidney disease (CKD). The complexity of calcium and phosphate disorders associated with CKD is defined by the Kidney Disease Improvement Global Outcomes (KDIGO) working group as CKD-related mineral and bone disorders (CKD-MBD). The last update of the KDIGO guidelines on the conduct in CKD-MBD was published in 2017. The treatment of SHPT is based on 2 strategies: counteracting hyperphosphataemia and suppressing parathyroid hormone (PTH) secretion. Therapy should be based on optimally selected drugs, taking into account additional effects to reduce the risk of chronic complications and side effects. The creation of new drugs with a better safety profile, significant reduction of side effects, and greater efficiency in achieving target serum phosphorus and PTH values forces the gradual replacement of existing treatment with new pharmacotherapies. The aim of this study is to discuss the latest issues (in connection with the latest KDIGO guidelines) regarding the pathomechanism of secondary hyperparathyroidism and the current directions of the therapy in these disorders.

A Parathyroid Hormone–Guided Calcium and Calcitriol Supplementation Protocol Reduces Hypocalcemia-Related Readmissions Following Total Thyroidectomy

ObjectiveTo determine the effect of a 4-hour postoperative serum parathyroid hormone (PTH)–guided calcium (Ca) and calcitriol supplementation protocol on the incidence of hypocalcemia and hospital readmissions in patients undergoing total thyroidectomy. MethodsThis was a single-institution, retrospective chart review of patients who underwent total thyroidectomy; 148 and 389 of the patients underwent surgery prior to and after the protocol implementation, respectively. The risk of hypocalcemia was stratified as low (PTH level of >30 pg/mL), medium (15-30 pg/mL), and high (<15 pg/mL), using serum PTH values obtained 4 hours postoperatively. Hypocalcemia was defined as a total serum Ca level of <8 mg/dL. Baseline demographic and operative characteristics and postoperative outcome were recorded for both groups. The Fisher exact test and Wilcoxon rank sum test were used to compare the characteristics of the 2 groups. A multivariate logistic regression model was applied to account for potentially confounding variables. ResultsPostoperative hypocalcemia occurred significantly less frequently in the protocol group compared with that in the preprotocol group (10.3% vs 20.9%, P = .002). The reduction in hypocalcemia in the protocol group was observed in both patients with (16.3% vs 25.6%) and without (8.4% vs 19.3%) cervical lymph node dissection. The protocol group had a significantly lower incidence of hospital readmission events than the preprotocol group (1.0% vs 4.7%, P = .013). ConclusionCompared with a historical cohort, a PTH-guided protocol for Ca and calcitriol supplementation significantly reduces the postoperative hypocalcemia and hospital readmission rates in patients undergoing total thyroidectomy.

Accuracy of Serum Parathyroid Hormone Measured on the Early Morning of the First Postoperative Day in Predicting Clinically Significant Post-Total Thyroidectomy Hypocalcemia.

Clinical hypocalcemia (CH) following total thyroidectomy (TT) is a potentially life-threatening condition if left untreated. This study aimed at evaluating the accuracy of parathyroid hormone (PTH) measured in the early morning of the first postoperative day (POD-1) in predicting CH, and determining the cutoff values of PTH that can predict the development of CH. We performed a retrospective review of patients undergoing TT between February 2018 and July 2022. Serum PTH, calcium, and albumin levels were measured on morning (6-8AM) of postoperative day one (POD-1), and serum calcium level was measured from POD-2 onwards. We performed ROC curve analysis to determine the accuracy of PTH in predicting postoperative CH, and cutoff values of PTH to predict CH. Ninety-one patients, 52 (57.1%) with benign and 39 (42.9%) with malignant goiter were included. The incidence of biochemical, and clinical hypocalcemia was 24.2% and 30.8%, respectively. In our study serum, PTH measured in the early morning of first postoperative day following TT was found to have good accuracy (AUC = .88) in predicting CH. A PTH value of ≥27.15pg/mL was found to have a 96.4% sensitivity in ruling out CH, while a serum PTH value <10.65pg/mL had a specificity of 95.2% in predicting CH. Patients with a serum PTH value of ≥27.15pg/mL can be discharged without any supplements, those with PTH <10.65pg/mL should be started on calcium and calcitriol supplements, while patients having PTH values between 10.65 and 27.15pg/mL should be monitored for the development of signs and/or symptoms of hypocalcemia.

Parathyroid Carcinoma with Low Values of Elevated Parathyroid Hormone: A Case Report

Parathyroid Carcinoma (PC) is a rare endocrine malignancy, accounting for &lt;1% of sporadic Primary Hyperparathyroidism (PHPT) cases. A preoperative and even intraoperative diagnosis of PC is rarely reported due to its close resemblance to parathyroid adenoma with respect to symptoms- hypercalcaemia, renal stones and/or failure, osteoporosis, and cardiac/neurocognitive dysfunction. The mean serum calcium in PC is reported to be greater than 14 mg/dL along with serum Parathyroid Hormone (PTH) levels often above 1000 pg/mL. When serum PTH levels are 10 times the upper limit of the normal, it is considered diagnostic of PC. Surgical en-bloc resection without capsular breach is the only definitive cure for PC. The present case report included two patients who presented with features of single parathyroid glandular enlargement, hypercalcaemia, its consequences and with normal ionised calcium, but relatively low levels of elevated serum PTH (&lt;300 pg/mL). They were operated and identified postoperatively as having PC. This rare presentation of PC where the preoperative serum PTH values were lower than usually seen in carcinoma, should alert endocrinologists and surgeons that lower levels of elevated serum PTH do not primarily exclude the possibility of carcinoma.

A Comparative Study to Assess Parathyroid Hormone Status in Different Age Groups of b-Thalassaemia Major Individuals from Eastern India

Introduction: β-thalassaemia major, due to imbalance, missing or deficiency of β-globin chain synthesis pathway, is marked as a hereditary disorder. Homozygous state presents with severe anaemia. Regular blood transfusions and chelation therapy increase the life expectancy in thalassaemia patients. Due to recent advances in the treatment paradigm of β-thalassaemia major patients, there has been a significant increase in their lifespan but, due to the treatment related iron overload, endocrine defects like hypogonadism, diabetes mellitus, hypothyroidism and Hypoparathyroidism (HPT) have been seen to progress. Diverse studies state the occurrence of HPT to be from none upto almost 22.5% in patients. It has also been recognised that asymptomatic hypocalcaemia is much more common and can be overlooked unless precisely viewed. Aim: To estimate and compare the biochemical parameters related to bone turnover in regularly transfused thalassaemia patients in different age groups and to find out significant correlation among the biochemical markers. Materials and Methods: In this cross-sectional study conducted at Calcutta National Medical College, Kolkata, West Bengal, India, from January 2017 till January 2018, 100 β-thalassaemia major patients were enrolled. Serum Parathyroid Hormone (PTH), serum ferritin, ionic calcium (Ca2+), Alkaline Phosphatase (ALP), phosphorus (P) and 25-Hydroxy vitamin D (25-OHD) levels were estimated in these patients. Statistical evaluation was done by the Statistical Package for the Social Sciences (SPSS), version 12.0. Result was reported as mean±SD. Pearson correlation coefficient was used to determine the association of serum ferritin levels and parathormone levels. The p-value of &lt;0.05 was considered as statistically significant. Results: Out of 100 patients, 19 patients had HPT. The mean age was found to be 12.6 years on diagnosis, mean ionised calcium was 0.95 mmol/L, mean serum ferritin was 3045 μg/L (range 1209-10,000 µg/L) and mean serum phosphate was 1.88 mmol/L (range 1.50-2.73 mmol/L). Serum PTH values of 7.04 pg/mL was found to be low. Negative correlation serum PTH and ferritin levels were found. Significant higher values of mean serum ferritin (2789 μg/L) and lower values of parathormone (17.13 pg/mL) was found in the age group of 11-18 years as compared to the other age group of ≤10 years with serum ferritin and parathormones values being 1648 μg/L and 23.44 pg/mL, respectively. Conclusion: Regularly transfused β-thalassaemia major patients, inspite of receiving chelation therapy tend to develop altered calcium and vitamin D homeostasis once they enter second decade of life. Thereby, biochemical parameters related to bone profile which includes ionic calcium, vitamin D, phosphate and parathyroid hormones levels should stringently monitored once the patient crosses first decade of life to prevent any development of hypocalcaemia or overt HPT.

Association Between Vitamin D Deficiency and Anemia in Pediatric Kidney Transplant Recipients.

The association between vitamin D deficiency and anemia is known. Vitamin D deficiency and anemia are common in kidney transplant recipients. We examined the relationship between vitamin D levels and anemia in pediatric kidney transplant recipients. We reviewed retrospectively the data of 75 pediatric kidney transplant recipients (0-18 years of age). Patients were evaluated in 3 groups according to serum 25-hydroxyvitamin D levels (<20, 20-30, and >30 ng/mL) in the first year posttransplant: group 1 was the vitamin D deficiency group, group 2 was the vitamin D insufficiency group, and group 3 was normal vitamin D level group, respectively. Groups were compared in terms of anemia parameters, calcium, phosphorus, alkaline phosphatase, and parathyroid hormone levels, as well as infection, rejection, and graft loss status. All patients included in the study were grouped as those with anemia and without anemia, and the 2 groups were compared in terms of vitamin D levels, serum parathyroid hormone values, estimated glomerular filtration rate, and infection, rejection, and graft loss status. There were 41 patients (54.7%) in group 1, 24 patients (32%) in group 2, and 10 patients (13%) in group 3. There were 65 patients (86.7%) with vitamin D deficiency/insufficiency. When groups were compared, the hematocrit level was found to be lower in groups 1 and 2 (P < .05) and ferritin level was found to be lower in group 1 (P < .05). Anemia was present in 20 patients (26.6%): 61% of patients with anemia had vitamin D deficiency and 33% had vitamin D insufficiency (P > .05). In total, 94% of patients with anemia had vitamin D deficiency/insufficiency. Vitamin D deficiency/insufficiency is common in pediatric kidney transplant recipients. Vitamin D levels should be measured, especially in all kidney transplant recipients with persistent anemia. Thus, risk factors associated anemia can be reduced by treating the deficiency/insufficiency.

Prediction of long-term dependence on vitamin D analogues following total thyroidectomy for Graves' disease.

This study aimed to identify patients at risk of long-term hypocalcaemia following total thyroidectomy for Graves' disease, and to determine the thresholds of postoperative day 1 serum calcium and parathyroid hormone (PTH) at which long-term activated vitamin D treatment can be safely excluded. This study was a retrospective analysis of 115 consecutive patients undergoing total thyroidectomy for Graves' disease at a university referral centre between 2010 and 2018. Outcome measures were the day 1 postoperative adjusted calcium and PTH results, and vitamin D analogue need at 6 months postoperatively. Logistic receiver operating curves were used to identify optimal cut-off values for adjusted serum calcium and serum PTH, and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Temporary hypocalcaemia was observed in 20.9% of patients (mean day 1 serum adjusted calcium 2.2±0.14mmol/l and PTH 4.15±2.42pmol/l). Long-term (>6 months) activated vitamin D analogue therapy was required in five patients (4.3%), four of whom had normal serum PTH and one with undetectable PTH at 6 weeks post surgery. No patient with a day 1 postoperative calcium >2.05mmol/l and detectable PTH required vitamin D supplementation at 6 months post surgery (100% sensitivity, PPV 50%, NPV 100%). The biochemical postoperative day 1 thresholds identified in this paper have a 100% NPV in the identification of patients who are likely to require either no or only temporary activated vitamin D supplementation. We were able to identify all patients requiring activated vitamin D supplementation 6 months postoperatively from the day 1 postoperative serum calcium and PTH values, while excluding those that may only need temporary calcium supplementation. These threshold levels could be used for targeted follow-up and management of this subset of patients most at risk of long-term hypocalcaemia.

Correlation Between Serum 25-hydroxyvitamin D Level and Cognitive Function Among the Elderly in Enugu State, Nigeria

<i>Background</i>: Low serum vitamin D is now implicated in many disease conditions among the elderly including cognitive impairment. Cognitive impairment is a common disease among elderly people causing much financial and social burden to the elderly, their families and caregivers. Therefore, the study aimed to determine the relationship between serum 25-hydroxyvitamin D (25(OH)D) concentration and cognitive function among elderly people in Enugu State, South-eastern Nigeria. <i>Methods</i>: This was a cross-sectional survey of subjects aged ≥ 60 years with cognitive impairment in communities and old People’s home in Enugu State in Nigeria and age- and sex-matched controls. The subjects were further divided into those with severe cognitive impairment and those with mild cognitive impairment using the Mini-Mental State Examination (MMSE). Serum 25(OH)D and parathyroid hormone (PTH) were assayed by enzyme-linked immune-sorbent assay while serum calcium, inorganic phosphate, and albumin were determined using the spectrophotometric method. Student t-test was used to compare mean values obtained, while Pearson correlation was used to determine relationships between continuous data. A p-value<0.05 was considered to be statistically significant. <i>Result</i>: One hundred and four (104) patients comprising of 58 males and 46 females were recruited for the current study. Among the study subjects compared to those of the controls, there were significantly decreased levels of serum 25(OH)D (p=0.0001) and the adjusted calcium (p=0.0001) concentrations but significantly increased level of serum PTH (p=0.0001) and inorganic phosphate (p=0.005) concentrations. Also, the mean values of serum 25(OH)D and adjusted calcium were significantly lower, serum PTH values were significantly higher while serum inorganic phosphate concentrations showed no significant difference for those with severe cognitive impairment when compared to values of those with mild cognitive impairment and controls. Additionally, there was also significant positive correlations between serum 25(OH)D and cognitive function (r=0.504, ρ<0.05). <i>Conclusion</i>: The study findings suggest that decreased serum Vitamin D concentration is associated with diminished cognitive function among the elderly and vice versa. Hence, the determination of Vitamin D status among elderly patients presenting with impairment of cognitive function is highly recommended. However, further studies are needed to validate findings from the present study.

PTH after Thyroidectomy as a Predictor of Post-Operative Hypocalcemia.

Post-thyroidectomy hypocalcemia is a frequent complication with significant morbidity, and has been shown to increase hospital stay and readmission rates. The evaluation of serum parathyroid hormone (PTH) levels after thyroidectomy represents a reliable method to predict post-thyroidectomy hypocalcemia, but it remains infrequently used. This retrospective study investigates serum PTH values 3 h after thyroidectomy as a predictor of hypocalcemia. In this study, we enrolled 141 patients aged between 27 and 71 years eligible for total thyroidectomy who presented with multinodular goiter, suspicious nodule on cytological examination, Graves’ disease, or toxic multinodular goiter. Three hours after total thyroidectomy, 53 patients (37.6%) showed a reduction in serum PTH. Of these patients 75.5% developed hypocalcemia by 24 h after surgery and 100% were hypocalcemic after 48 h (p < 0.001). There was no significant difference attributable to the different thyroid diseases, nor to the age of the patients. PTH at 3 h after total thyroidectomy accurately predicts post-operative hypocalcemia. The early detection of patients at risk of developing post-operative hypocalcemia allows for prompt supplementation of calcium and Vitamin D in order to prevent symptoms and allows for a safe and timely discharge.

Value of serum parathyroid hormone in the diagnosis of primary aldosteronism

Objective: To explore the value of serum parathyroid hormone (PTH) in the diagnosis of primary aldosteronism (PA) and to investigate an optimal cut-off of serum PTH to distinguish PA from nonfunctional adrenal tumor (NFA). Methods: The clinical data of patients with adrenal incidentaloma in Chinese PLA General Hospital from January 1, 2017 to December 31, 2019 were collected. The data of PA and NFA by clinical characteristics and evaluation on endocrine function were retrospectively analyzed. The logistic regression model was used to find the potential risk factors of elevated PTH. The receiver operating characteristic(ROC) curve was used to evaluate the efficacy of PTH in diagnosis of PA and to explore the best cut-off value. Results: A total of 773 patients were included. There were 356 PA patients (203 males, 57.0%), aged (50±11) years and 417 NFA patients (219 males, 52.5%), aged (51±12) years. The serum PTH level in patients with PA was significantly higher than that in patients with NFA [63.1 (48.4, 80.3) ng/L vs 41.7 (34.1, 51.7) ng/L, P<0.05], as well as the proportion of patients with elevated PTH level (47.8% vs 7.2%, P<0.05). Logistic regression analysis showed that having PA and deficiency of Vitamin D were risk factors for PTH elevation (both P<0.05). The ROC curve showed that the best cut-off value of PTH for the diagnosis of PA in patients with vitamin D deficiency was 56.44 ng/L, with a sensitivity of 66.5% and a specificity of 83.0%, and that in patients with normal vitamin D was 48.81 ng/L, with a sensitivity of 70.5% and a specificity of 72.6%. Conclusions: Patients with PA tend to show increased levels of serum PTH compared with NFA patients. The level of serum PTH can be used as one of the valuable indexes in screening of PA.

Primary Aldosteronism with Parathyroid Hormone Elevation: A Single-center Retrospective Study.

Objective Primary aldosteronism (PA) is a major cause of secondary hypertension. The association between PA and other hormone disorders is unclear. The present study aimed to evaluate whether the parathyroid hormone (PTH) value is associated with PA subtypes or specific treatments. Methods We enrolled 135 patients with PA who had their PTH value measured before undergoing a specific treatment. We evaluated whether PTH value is associated with PA subtypes or with specific treatments. The present study is a single-center retrospective study (2011-2018). Results Our study showed that, among the patients with PA, the proportion of those with PTH elevation was >30%. The PTH value was significantly correlated with both the basal plasma aldosterone concentration (PAC) and PAC after a captopril challenge test. However, the PTH value was not significantly different between the patients with unilateral and bilateral PA. We observed that the serum PTH value decreased after treatment of PA with unilateral adrenalectomy or mineralocorticoid receptor antagonists. Conclusion Our findings suggest that the PTH value in PA patients might be associated with the autonomous production of aldosterone. However, there was no correlation between the PTH value and PA subtypes in our study. Additionally, our study showed that targeted treatment for PA may lead to a decrease in the serum PTH levels. Hence, the PTH value could potentially be used as an index for measuring the suitability for PA treatment.

Evaluation for Primary Hyperparathyroidism in Patients Who Present With Nephrolithiasis

The incidence of primary hyperparathyroidism (PHP) is likely underestimated. Nephrolithiasis may indicate PHP with indication for parathyroidectomy. We sought to determine the proportion of patients with an index diagnosis of nephrolithiasis that have serum calcium levels measured, parathyroid hormone (PTH) levels measured if hypercalcemic, and time to referral for definitive management if PHP is diagnosed. A single-institution retrospective review was performed of adult patients presenting with nephrolithiasis between July 1, 2016 and December 31, 2018. Exclusion criteria included currently admitted patients, prior nephrolithiasis, congenital or acquired urinary tract anomalies, and patients on calciuretics. Records were assessed for serum calcium and PTH measurement, as well as referrals. Univariate statistical analysis was performed. Of 1782 patients with nephrolithiasis screened, 968 met inclusion criteria. Patients were 49.8% female, 88.9% white. Mean age was 53y. Within this cohort, 620 (64.0%) patients had a calcium measured, with a mean elapsed time from presentation of 27d (interquartile range [IQR] 0-8). Twelve patients (1.58%) with calcium measured were hypercalcemic and eight (66.7%) had PTH measured with a mean elapsed time from presentation of 183d (IQR 72-310), all had elevated or non-suppressed PTH. Five (62.5%) were referred to surgeons with mean elapsed referral time of 270d (IQR 95-492). Many with index nephrolithiasis are not assessed for hypercalcemia or hyperparathyroidism. Patients with serum calcium and PTH values indicating PHP diagnosis may have significant delay to parathyroidectomy. Targeted interventions with electronic health record alerts or automated reflex testing may improve care in this domain.

Identifying early postoperative serum parathyroid hormone levels as predictors of hypocalcaemia after total thyroidectomy: A prospective non-randomized study.

There is no clear cut-off value of serum parathyroid hormone (PTH) or calcium in which patients are at risk for hypocalcemia after total thyroidectomy. We evaluated the usefulness of serum calcium and PTH concentration measurements after total thyroidectomy in predicting late-occurring hypocalcemia. A prospective, single-center, non-randomized longitudinal cohort study of 143 patients undergoing thyroidectomy between August 2019 and December 2019 with serum calcium and PTH levels sampled 1 h after surgery and on the first and fifth postoperative day. Hypocalcemia was defined as serum calcium levels < 2.14 mmol/L regardless of clinical symptoms. Normal PTH range was 1.6-6.9 pmol/L. The primary outcome measure was presence of hypocalcemia on the first and fifth postoperative day, analyzed by a logistic regression model. The PTH cut-off value for prediction of hypocalcemia was identified using a ROC curve comparing all three time points using the Youden J index. Out of 143 patients, 52 (36.4%) had hypocalcemia on the fifth postoperative day. Advanced age, concomitant neck dissection and serum PTH levels < 2.9 pmol/L 1 h after surgery and on the first postoperative surgery day were associated with a high risk of hypocalcemia on the first and fifth postoperative day and need for higher doses of calcium supplements (P < 0.0001, AUC 0.748, 95% CI 0.669-0.817, with 76.92% sensitivity and 71.43% specificity). Serum PTH level measured immediately postoperatively and on the first postoperative day is a reliable predictor of postoperative hypocalcemia with important clinical implications.

Follow up of Patients with Parathyroid Adenoma Detected by Parathyroid Scan

&lt;p&gt;&lt;strong&gt;&lt;em&gt;Background:&lt;/em&gt;&lt;/strong&gt; Primary hyperparathyroidism (PHPT) is the third most endocrine disorder after diabetes and thyroid disease. The objective of this study was to observe the outcome of those patients who had positive parathyroid scan with Technetium-99m (&lt;sup&gt;99m&lt;/sup&gt;Tc) sestamibi scan referred to National Institute of Nuclear Medicine &amp;amp; Allied Sciences (NINMAS) to perform parathyroid scan.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Patients and Methods&lt;/em&gt;&lt;/strong&gt;&lt;em&gt;:&lt;/em&gt; This longitudinal observational type of study was carried out at NINMAS, from January 2016 to December 2016. A total number of 43 hyperparathyroid patients who had positive parathyroid scan were included in this study during one year follow up period. There clinical status, biochemical profile &amp;amp; treatment history were evaluated Chi-quire and paired t-test were used to analyze the variables.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Results:&lt;/em&gt;&lt;/strong&gt;&lt;strong&gt; &lt;/strong&gt;Among 43 study patients, number of male patients was 26 (60.5%) and female patients were 17 (39.5%). The mean ± SD age was 42.44 ± 12.11 years and majority was in age group 41-50 years&lt;strong&gt;. &lt;/strong&gt;It was observed that 40 (93.0%) patients were symptomatic and only 3 (7.0%) were asymptomatic. Regarding symptoms, majority (81.4%) patients had bone pain followed by renal stone (58.1%). More than half (55.8%) patient had abdominal pain or cramps. Twenty nine (67.4.0%) patients undergone operation and 14 (32.6%) patients did not receive operative treatment at the one year follow up period. Among 43 patients 29 (67.4%) were operated and all operated patients relieved their symptoms whereas patients 14 (32.6%) had not undergone operation and their symptoms persisted. There was strong statistical significant association (P&amp;lt;0.05) between operation and relief of symptoms. The biochemical profile of study patients showed that preoperative mean serum calcium level was 10.92±2.85 mg/dl which reduced after operation (7.53±2.75 mg/dl). The mean value of serum parathyroid hormone (PTH) level also reduced from 748±744.77 pg/ml to 171.61±168.23 pg/ml.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Conclusion:&lt;/em&gt;&lt;/strong&gt; Among all patients, 67.4% received operative treatment and were relieved from symptoms at one year follow up. Significant number of hyperparathyroid patients (32.6%) failed to receive operative treatment due to poor economic condition. More awareness is needed among physicians and patients about immediate operative treatment to alleviate their sufferings as well as to avoid crippling complications.&lt;/p&gt;&lt;p&gt;Bangladesh J. Nuclear Med. 20(2): 119-123, July 2017&lt;/p&gt;

Osteolytic lesions (brown tumors) of primary hyperparathyroidism misdiagnosed as multifocal giant cell tumor of the distal ulna and radius: a case report

BackgroundBrown tumors represent a rare clinical manifestation reported in approximately 3% of patients with primary hyperparathyroidism and correspond to radiologically osteolytic lesions with well-defined borders in different parts of the skeleton.Case presentationWe report the case of a 53-year-old white man who presented to our hospital with osteolytic lesions of his distal ulna and radius, causing pain and swelling of 2-month duration. A subsequent biopsy revealed histological features consistent with giant cell tumor and a complete resection of his distal ulna was followed, along with curettage and cementoplasty of the distal radial metaphysis. Two weeks later, he was re-admitted with diffuse musculoskeletal soreness, anorexia, constipation, nausea, and localized abdominal pain and multiple osteolytic lesions on plain radiographs. A histopathological examination of the ulna and radius specimens showed similar findings and, given the multifocality, brown tumors related to primary or secondary hyperparathyroidism was included in the differential diagnosis. A laboratory examination showed high total serum calcium (14.5 mg/dl) and low serum phosphorus and 25-hydroxyvitamin D levels. Primary hyperparathyroidism was suspected and confirmed by the elevated parathyroid hormone levels of 1453 pg/mL. At radiological work-up, using computed tomography, ultrasonography, and parathyroid subtraction technetium-99m sestamibi scintigraphy, a 4.5 × 2.5 × 3.2 cm mass emanating from the right lobe of his thyroid gland was detected, displaying extensive uptake in the right lower parathyroid gland. After appropriate medical support including hyperhydration and high doses of diuretics and diphosphonates, his laboratory profile normalized and he underwent total thyroidectomy with removal of the parathyroid glands. Our patient is now recovering 12 months after surgery, with normal values of serum parathyroid hormone and calcium levels. The lytic bone lesions have almost disappeared and no other additional orthopedic intervention was necessary.ConclusionsThe present case report emphasizes the need of inclusion of brown tumors in the differential diagnosis of multifocal osteolytic bone lesions, in order to avoid harmful surgical interventions. Laboratory testing of serum phosphate, calcium levels, and parathyroid hormone levels should always be included in the routine survey of patients with multifocal osteolytic lesions.

Vitamin D Treatment Effect on Serum Endocan and High-Sensitivity C-Reactive Protein Levels in Renal Transplant Patients.

Endocan is a marker showing endothelial dysfunction and inflammation. Significantly increased endocan levels have been observed in serum of patients with sepsis and cancer. Our aim was to investigate the relationship between vitamin D treatment and serum endocan and high-sensitivity C-reactive protein (hs-CRP) levels as inflammatory markers in transplant patients. Prospective. Nephrology clinic. Thirty-eight renal transplant patients with serum 25-hydroxy-vitamin D (25-OH-vitamin D) levels below 20 ng/mL and transplanted at least 12 months. One-time oral dose of 300 000 IU vitamin D3. Before and after vitamin D treatment, serum endocan, hs-CRP, calcium, phosphorus, and parathyroid hormone (PTH) levels were measured. Median serum endocan and PTH values before vitamin D were significantly higher than those of after treatment values ( P = .001 and P < .001, respectively). On the other hand, serum total calcium and phosphorus levels before vitamin D treatment were lower than the values obtained after vitamin D treatment ( P = .0013 and P < .001, respectively). Serum hs-CRP was lower after vitamin D therapy than before, but the difference was not statistically significant ( P = .06). A moderate negative correlation was determined between endocan and 25-OH-vitamin D levels after treatment with vitamin D ( r = -.36, P = .02). This study has revealed that vitamin D treatment reduced markers of endothelial dysfunction in patients with renal transplantation and vitamin D deficiency.

The levels of bone turnover markers 25(OH)D and PTH and their relationship with bone mineral density in postmenopausal women in a suburban district in China

The aims of this study were to evaluate the levels of bone turnover markers (BTMs), including serum N-terminal procollagen of type I collagen (P1NP), beta C-terminal cross-linked of type I collagen (β-CTX), 25-hydroxyvitamin D [25(OH)D], and parathyroid hormone (PTH), and to investigate relationships between these markers and bone mineral density (BMD) as well the prevalence of osteoporosis in postmenopausal women of suburban district. A population of 4822 postmenopausal women aged 55-69years old (62.22 ± 6.75) from the suburban district was recruited voluntarily. BMD was measured at the lumbar spine, femoral neck, and total hip using dual-energy X-ray absorptiometry; 2251 women in this group had the serum BTMs 25(OH)D and PTH tested. The prevalence of osteoporosis was 25.03% at lumbar spine and 6.23% at femoral neck. The median (interquartile range) values of serum P1NP, β-CTX, 25(OH)D, and PTH were 59.3ng/mL (44.7-75.52), 0.370ng/mL (0.280-0.490), 23.0ng/mL (17.1-30.5), and 31.4pg/mL (24.9-39.7), respectively. Serum P1NP and β-CTX levels presented significantly negative correlations with BMDs at the all the sites (Betastd = -0.098 to -0.208, respectively, P < 0.001), whereas PTH levels were negatively correlated with BMDs of the femoral neck and total hip (Betastd = -0.062 and -0.054, P < 0.01, respectively). Serum 25(OH)D had positive associations with BMDs at total hip (Betastd = 0.051, P < 0.01). The BMD of postmenopausal women in China suburban area is higher than that in downtown area, and over 60% of the participants had their serum 25(OH)D level over 20ng/mL. BTMs were negatively correlated with BMDs, suggesting that BTMs are reliable factors for early declines in BMD.

High frequency of asymptomatic hyperparathyroidism in patients with fibromyalgia: random association or misdiagnosis?

Fibromyalgia (FM) and hyperparathyroidism may present similar symptoms (musculoskeletal pain, cognitive disorders, insomnia, depression and anxiety), causing diagnostic confusion. ObjectivesTo determine the frequency of asymptomatic hyperparathyroidism in a sample of patients with FM and to evaluate the association of laboratory abnormalities to clinical symptoms. MethodsCross-sectional study with 100 women with FM and 57 healthy women (comparison group). Parathyroid hormone (PTH), calcium and albumin levels were accessed, as well as symptoms in the FM group. ResultsIn FM group, mean serum calcium (9.6±0.98mg/dL) and PTH (57.06±68.98pg/mL) values were considered normal, although PTH levels had been significantly higher than in the comparison group (37.12±19.02pg/mL; p=0.001). Hypercalcemic hyperparathyroidism was diagnosed in 6% of patients with FM, and 17% of these women exhibited only high levels of PTH, featuring a normocalcemic hyperparathyroidism, with higher frequencies than those expected for their age. There was no significant association between hyperparathyroidism and FM symptoms, except for epigastric pain, which was more frequent in the group of patients concomitantly with both diseases (p=0.012). ConclusionsA high frequency of hyperparathyroidism was noted in women with FM versus the general population. Normocalcemic hyperparathyroidism was also more frequent in patients with FM. Longitudinal studies with greater number of patients are needed to assess whether this is an association by chance only, if the increased serum levels of PTH are part of FM pathophysiology, or even if these would not be cases of FM, but of hyperparathyroidism.

Frequência elevada de hiperparatireoidismo assintomático em pacientes com fibromialgia: associação ao acaso ou erro diagnóstico?

Fibromyalgia (FM) and hyperparathyroidism may present similar symptoms (musculoskeletal pain, cognitive disorders, insomnia, depression and anxiety), causing diagnostic confusion. ObjectivesTo determine the frequency of asymptomatic hyperparathyroidism in a sample of patients with FM and to evaluate the association of laboratory abnormalities to clinical symptoms. MethodsCross‐sectional study with 100 women with FM and 57 healthy women (control group). Parathyroid hormone (PTH), calcium and albumin levels were accessed, as well as symptoms in the FM group. ResultsIn FM group, mean serum calcium (9.6±0.98mg/dL) and PTH (57.06±68,98 pg/mL) values were considered normal, although PTH levels had been significantly higher than in the control group (37.12±19.02 pg/mL; p=0.001). Hypercalcemic hyperparathyroidism was diagnosed in 6% of patients with FM, and 17% of these women exhibited only high levels of PTH, featuring a normocalcemic hyperparathyroidism, with higher frequencies than those expected for their age. There was no significant association between hyperparathyroidism and FM symptoms, except for epigastric pain, which was more frequent in the group of patients concomitantly with both diseases (p=0.012). ConclusionsA high frequency of hyperparathyroidism was noted in women with FM versus the general population. Normocalcemic hyperparathyroidism was also more frequent in patients with FM. Longitudinal studies with greater number of patients are needed to assess whether this is an association by chance only, if the increased serum levels of PTH are part of FM pathophysiology, or even if these would not be cases of FM, but of hyperparathyroidism.

Vitamin D-Dependent Rickets: Eight cases

Objective: Vitamin D is essential for bone development and health, and deficiency resulting in rickets and skeletal defor mities is seen mainly during rapid growth. Hereditary vitamin D dependent rickets type I and type II rickets is a very rare form of rickets, characterized by 1-alpha-hydroxylase defi ciency or end-organ resistance to vitamin D. We aimed to investigate, clinical and laboratory characteristics of eight cases with Vitamin D-dependent rickets (VDRR). Method: The mean age of patients during diagnosis was 2.6 years. Excluding one patient, others were males (87.5%). Results: Mean laboratory values during referral was calcium 7.5±1,5 mg/dl, phosphorus 4±1.2 mg/dl, alkaline phosphatase (ALP) 1679±641 U/L and parathyroid hormone (PTH) 524±498 pg/ml. Patients received 1.2 µg/kg/day calcitriol. During follow-ups serum ALP and PTH values of patients turned to normal levels. Conclusion: In rickets, cases with persistent increased serum ALP and PTH levels it will be appropriate to investigate serum 25 (OH) D levels in cases diagnosed with vitamin D-dependent rickets even though hypocalcaemia is absent. Administration of adequate doses of calcitriol in some cases is able to clinical and laboratory values return to normal.