Advances in Clinical and Experimental Medicine
2016, vol. 25, nr 2, March-April, p. 285–293
Publication type: original article
Interdisciplinary Aspects of Primary Hyperparathyroidism: Symptomatology in a Series of 100 Cases
1 Department and Clinic of Internal and Occupational Diseases and Hypertension, Wroclaw Medical University, Poland
2 Department and Clinic of Urology, Wroclaw Medical University, Poland
3 Department and Clinic of Endocrinology, Diabetology and Isotope Therapy, Wroclaw Medical University, Poland
Background. Primary hyperparathyroidism (PHPT) is a common endocrine disorder. Beside renal and skeletal complications, it has a wide variety of nonspecific symptoms from other organs that mimic other diseases and delay the diagnosis. In recent decades the clinical profile of PHPT has evolved to less symptomatic forms.
Objectives. The aim of the study was to revise the symptomatology profile of PHPT in a single region, and to facilitate early PHPT diagnosis by encouraging interdisciplinary communication among medical professionals.
Material and Methods. Data from 100 patients (94 women and 6 men, aged 57.1 ± 13.7 years) diagnosed with PHPT in the authors’ center during the past decade were retrospectively analyzed. Biochemical conditions and clinical manifestations (renal, skeletal, cardiovascular, gastrointestinal and asymptomatic) were evaluated.
Results. Renal symptoms were present in 55% of the patients. In the course of unrecognized disease, seven lithotripsy procedures, seven surgical lithotomy procedures and two nephrectomies were performed. Osteoporosis/ /osteopenia was present in 66% and 10% of the study group, respectively. In 16% there were fragility fractures; in 10% brown tumors were present, and 55% of the PHPT patients were hypertensive. Gastrointestinal symptoms were present in 52%; pancreatitis was documented in 3%. PHPT was diagnosed incidentally in asymptomatic patients in 15% of the group. Mean serum Ca was 2.87 mmol/L (SD: 0.36), mean urine Ca was 15.97 mEq/24 h (SD: 7.89), mean serum PTH was 324 pg/mL (SD 425.21). The duration from the appearance of any symptom to the diagnosis varied from < 1 year (19%), 1–10 years (46%) to > 10 years (35%).
Conclusion. PHPT is still diagnosed too late, after a period of untreated symptomatic disease. Multidisciplinary cooperation among specialists on the diagnostic level can help avoid late complications of unrecognized disease.
osteoporosis, osteoporotic fractures, primary hyperparathyroidism, nephrolithiasis, osteitis fibrosa cystica
- Clarke BL: Epidemiology of Primary Hyperparathyroidism. J Clin Densitom: Assessment of Skeletal Health 2013, 16, 8–13.
- Adami S, Marcocci C, Gatti D: Epidemiology of primary hyperparathyroidism in Europe. J Bone Miner Res 2002, 17, Suppl 2, 18–23.
- Giusti F, Cavalli L, Cavalli T, Brandi ML: Hereditary Hyperparathyroidism Syndromes: J Clin Densitom: Assessment of Skeletal Health 2013, 16, 69–74.
- Abood A, Vestergaard P: Increasing incidence of primary hyperparathyroidism in Denmark. Dan Med J 2013, 60, 4567.
- Albright F, Aub JC, BauerW: Hyperparathyroidism: a common and polymorphic condition as illustrated by seventeen proved cases from one clinic. JAMA 1934, 102, 1276–1287.
- Tupikowski K, Bucyk B, Florczak A, Karwacki J, Dembowski J, Zdrojowy R, Bednarek-Tupikowska G: Przypadek kamicy nerkowej w przebiegu pierwotnej nadczynności przytarczyc. Urol Pol 2008, 61, 246–248.
- Ribeiro SLE, Souza ERV, Scrignoli JA, Bezerra FC, Passos LFS: Devastating Skeletal Effects of Delayed Diagnosis of Complicated Primary Hyperparathyroidism Because of Ectopic Adenoma. J Clin Rheumatol 2008, 14, 281–284.
- Pawlak W, Bohdanowicz-Pawlak A, Bolanowski M, Szymczak J, Bednarek-Tupikowska G, Luczak K: Primary hyperparathyroidism presenting as a giant cell tumor of the jaws. Neuroendocrinol Lett 2013, 34, 107–110.
- Silverberg SJ: Asymptomatic Primary Hyperparathyroidism. J Clin Densitom: Assessment of Skeletal Health 2013, 16, 14–21.
- Staszków M, Wojtaszek E, Żebrowski P, Matuszkiewicz-Rowińska J: Massive soft tissue calcifications in severe hyperparathyroidism secondary to end-stage renal disease. Pol Arch Med Wewn 2013, 123, 191–192.
- Gawrychowski J, Buła G: Imaging diagnostics for primary hyperparathyroidism. Endokrynol Pol 2013, 64, 404–408.
- Sorensen MD, Duh QY, Grogan RH, Tran TC, Stoller ML: Urinary parameters as predictors of primary hyperparathyroidism in patients with nephrolithiasis. J Urol 2012, 187, 516–521.
- Marques TF, Vasconcelos R, Diniz E, Rêgo D, Griz L, Bandeira F: Normocalcemic primary hyperparathyroidism in clinical practice: an indolent condition or a silent threat? Arq Bras Endocrinol Metab 2011, 55, 314–317.
- Yu N, Leese GP, Smith D, Donnan PT: The natural history of treated and untreated primary hyperparathyroidism: the parathyroid epidemiology and audit research study. QJ Med 2011, 104, 513–521.
- Rubin MR, Bilezikian JP, McMahon DJ, Jacobs T, Shane E, Siris E, Udesky J, Silverberg SJ: The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15-years. JCEM 2008, 93, 3462–3470.
- Amaral LM, Queiroz DC, Marques TF, Mendes M, Bandeira F: Normocalcemic vs. hypercalcemic primary hyperparathyroidism: more stone than bone? J Osteoporos 2012, 2012, 128352.
- Yu N, Donnan PT, Flynn RWV, Murphy MJ, Smith D, Rudman A, Leese GP: Increased mortality and morbidity in mild primary hyperparathyroid patients the parathyroid epidemiology and audit research study (PEARS). Clin Endocrinol 2010, 73, 30–34.
- Mazeh H, Mazeh H, Sippel RS, Chen H: The Role of Gender in Primary Hyperparathyroidism: Same Disease, Different Presentation. FACS Ann Surg Oncol 2012, 19, 2958–2962.
- Parisien M, Cosman F, Mellish RW, Schnitzer M, Nieves J, Silverberg SJ, Shane E, Kimmel D, Recker RR, Bilezikian JP, Lindsay R, Dempster DW: Bone structure in postmenopausal hyperparathyroid, osteoporotic, and normal women. J Bone Miner Res 1995, 10, 1393–1399.
- Siilin H, Lundgren E, Mallmin H, Mellstrom D, Ohlsson, C, Karlsson, M, Orwoll, E, Ljunggren O: Prevalence of Primary Hyperparathyroidism and Impact on Bone Mineral Density in Elderly Men: MrOs Sweden. World J Surg 2011, 35, 1266–1272.
- Silverberg SJ, Shane E, de la Cruz L, Dempster DW, Feldman F, Seldin D, Jacobs TP, Siris ES, Cafferty M, Parisien MV, Lindsay R, Clemens TL, Bilezikian JP: Skeletal disease in primary hyperparathyroidism. J Bone Miner Res 1989, 4, 283–291.
- Lewiecki EM, Miller PD: Skeletal effects of primary hyperparathyroidism: Bone mineral density and fracture risk. J Clin Densitom: Assessment of Skeletal Health 2013, 16, 28–32.
- Silverberg SJ, Shane E, Jacobs TP, Siris E, Bilezikian JP: A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. NEJM 1999, 341, 1249–1255.
- Vu TD, Wang XF, Wang Q, Cusano NE, Irani D, Silva BC, Ghasem-Zadeh A, Udesky J, Romano ME, Zebaze R, Jerums G, Boutroy S, Bilezikian JP, Seeman E: New insights into the effects of primary hyperparathyroidism on the cortical and trabecular compartments of bone. Bone 2013, 55, 57–63.
- Yu HI, Lu CH: Sacroiliitis-like pain as the initial presentation of primary hyperparathyroidism. Arch Osteoporos 2012, 7, 315–318.
- Walker MD, Rubin M, Silverberg SJ: Nontraditional manifestations of primary hyperparathyroidism. J Clin Densitom: Assessment of Skeletal Health 2013, 16, 40–47.
- Ellison EH, Abrams JS, Smith DJ: A postmortem analysis of 812 gastroduodenal ulcers found in 20,000 consecutive autopsies, with emphasis on associated endocrine disease. Am J Surg 1959, 97, 17–30.
- Abboud B, Daher R, Boujaoude J: Digestive manifestations of parathyroid disorders. World J Gastroenterol 2011, 17, 4063–4066.
- Mruthyunjaya MD, Abraham DT, Oommen R, Paul TV: Ectopic primary hyperparathyroidism with recurrent pancreatitis. Endocr Pract 2013, 19, 383.
- Bai HX, Giefer M, Patel M, Orabi AI, Husain SZ: The Association of primary hyperparathyroidism with pancreatitis. J Clin Gastroenterol 2012, 46, 656–661.
- Massironi S, Cavalcoli F, Rossi RE, Conte D, Spampatti MP, Ciafardini C, Verga U, Beck-Peccoz P, Peracchi M: Chronic autoimmune atrophic gastritis associated with primary hyperparathyroidism: A transversal prospective study. EJE 2013, 168, 755–761.
- Werner S, Hjern B, Sjöberg HE: Primary hyperparathyroidism. Analysis of findings in a series of 129 patients. Acta Chir Scand 1974,140, 618–625.
- Bhadada SK, Bhansali A, Shah VN, Behera A, Ravikiran M, Santosh R: High prevalence of cholelithiasis in primary hyperparathyroidism: a retrospective analysis of 120 cases. Indian J Gastroenterol 2011, 30, 100–101.
- Chan AK, Duh QY, Katz MH, Siperstein AE, Clark OH: Clinical manifestations of primary hyperparathyroidism before and after parathyroidectomy. A case-control study. Ann Surg 1995, 222, 402–414.
- Hedbäck GM, Odén AS: Cardiovascular disease, hypertension and renal function in primary hyperparathyroidism. J Intern Med 2002, 251, 476–483.
- Feldstein CA, Akopian M, Pietrobelli D, Olivieri A, Garrido D: Long-term effects of parathyroidectomy on hypertension prevalence and circadian blood pressure profile in primary hyperparathyroidism parathyroidectomy effects on hypertension in PHPT. Clin Exp Hypertens 2010, 32, 154–158.
- Petramala L, Formicuccia MC, Zinnamosca L, Marinelli C, Cilenti G, Colangelo L, Panzironi G, Cerci S, Sciomer S, Ciardi A, Cavallaro G, De Toma G, Letizia C: Arterial hypertension, metabolic syndrome and subclinical cardiovascular organ damage in patients with asymptomatic primary hyperparathyroidism before and after parathyroidectomy: Preliminary results. Intern J Endocrinol 2012, Article ID 408295, 10 pages. DOI:10.1155/2012/408295.
- Hulter HN, Melby JC, Peterson JC, Cooke CR: Chronic continuous PTH infusion results in hypertension in normal subjects. J Clin Hypertens 1986, 2, 360–370.
- Macfarlane DP, Yu N, Donnan PT, Leese GP: Should “mild primary hyperparathyroidism” be reclassified as “insidious”: is it time to reconsider? Clin Endocrinol (Oxf) 2011, 75, 730–737.
- Andersson P, Rydberg E, Willenheimer R: Primary hyperparathyroidism and heart disease – a review. Eur Heart J 2004, 25, 1776–1787.
- Yu N, Leese GP, Donnan PT: What predicts adverse outcomes in untreated primary hyperparathyroidism? The Parathyroid Epidemiology and Audit Research Study (PEARS). Clin Endocrinol (Oxf) 2013, 79, 27–34.
- Walker MD, Fleischer JB, Di Tullio MR, Homma S, Rundek T, Stein EM, Zhang C, Taggart T, McMahon DJ, Silverberg SJ: Cardiac Structure and Diastolic Function in Mild Primary Hyperparathyroidism. JCEM 2010, 95, 2172–2179.
- Hagström E, Hellman P, Larsson TE, Ingelsson E, Berglund L, Sundström J, Melhus H, Held C, Lind L, Michaëlsson K, Arnlöv J: Plasma parathyroid hormone and the risk of cardiovascular mortality in the community. Circulation 2009, 119, 2765–2771.
- Cawthon PM, Parimi N, Barrett-Connor E, Laughlin GA, Ensrud KE, Hoffman AR, Shikany JM, Cauley JA, Lane NE, Bauer DC, Orwoll ES, Cummings SR, Osteoporotic Fractures in Men (MrOS) Research Group: Serum 25-hydroxyvitamin D, parathyroid hormone, and mortality in older men. JCEM 2010, 95, 4625–4634.
- Bosworth C, Sachs MC, Duprez D, Hoofnagle AN, Ix JH, Jacobs DR Jr, Peralta CA, Siscovick DS, Kestenbaum B, de Boer IH: Parathyroid hormone and arterial dysfunction in the multi-ethnic study of atherosclerosis. Clin Endocrinol (Oxf) 2013, 79, 429–436.
- Pepe J, Curione M, Morelli S, Colotto M, Varrenti M, Castro C, D’Angelo A, Cipriani C, Piemonte S, Romagnoli E, Minisola S: Arrhythmias in primary hyperparathyroidism evaluated by exercise test; Eur J Clin Invest 2013, 43, 208–214.
- Piovesan A, Molineri N, Casasso F, Emmolo I, Ugliengo G, Cesario F, Borretta G: Left ventricular hypertrophy in primary hyperparathyroidism. Effects of successful parathyroidectomy. Clin Endocrinol (Oxf) 1999, 50, 321–328.