Signs and Symptoms of Primary Hyperparathyroidism

Below is your **complete, expanded, exam-ready + clinically robust reference** on **Primary Hyperparathyroidism (PHPT)** following **your template**: **Definition → Pathophysiology → Causes → Clinical Features → Investigations → Differential Diagnosis → Management (stepwise) → Drug details → Monitoring → Counselling** — **Concise but exhaustive**, suitable for NEET PG + physicians + your ErrorOn Space content. --- # **PRIMARY HYPERPARATHYROIDISM (PHPT) – COMPLETE DETAILED NOTE** --- # **1) Definition** Primary hyperparathyroidism is a disorder characterized by **autonomous overproduction of parathyroid hormone (PTH)** from one or more parathyroid glands, leading to **hypercalcemia** and **hypophosphatemia** with widespread metabolic, renal, skeletal, and neuropsychiatric effects. --- # **2) Pathophysiology** Excess PTH causes: ### **A. Bone** * ↑ Osteoclast activity * ↑ Bone resorption * Cortical bone loss (radius most affected) * Osteitis fibrosa cystica (late) ### **B. Kidneys** * ↑ Calcium reabsorption * ↓ Phosphate reabsorption → **hypophosphatemia** * ↑ 1α-hydroxylase → ↑ 1,25-(OH)₂-Vitamin D → ↑ gut calcium absorption * Nephrolithiasis and nephrocalcinosis ### **C. GI** * ↑ Gastrin → peptic ulcer * ↑ Calcium absorption ### **D. Cardiovascular** * Short QT interval * Hypertension * Arrhythmias (rare) --- # **3) Etiology (Causes)** ### **A. Parathyroid Adenoma (80–85%)** Single adenoma most common. ### **B. Parathyroid Hyperplasia (10–15%)** All four glands enlarged. ### **C. Parathyroid Carcinoma (<1%)** Severe hypercalcemia, palpable neck mass. ### **D. Genetic Syndromes** * MEN 1 * MEN 2A * Familial isolated hyperparathyroidism * Familial hypocalciuric hypercalcemia (FHH) – mimics PHPT but NOT PHPT ### **E. Radiation Exposure** Childhood neck radiation increases risk. --- # **4) Clinical Features** Mnemonic: **“Stones, Bones, Groans, Thrones, Psychiatric Overtones”** ### **A. Renal** * Nephrolithiasis * Nephrocalcinosis * Polyuria, polydipsia * Dehydration * CKD ### **B. Skeletal** * Bone pain * Cortical osteoporosis * Pathological fractures * Brown tumors * Subperiosteal erosions ### **C. GI** * Nausea, vomiting * Constipation * Pancreatitis * Peptic ulcer disease * Abdominal pain ### **D. Neuropsychiatric** * Fatigue * Depression * Cognitive dysfunction * Confusion (hypercalcemic crisis) ### **E. Cardiovascular** * Hypertension * Short QT interval ### **F. Musculoskeletal** * Proximal myopathy * Generalized weakness ### **G. Others** * Corneal calcification (band keratopathy) --- # **5) Investigations (Stepwise)** ## **A. Initial Tests** | Test | Typical Finding in PHPT | | --------------------- | ------------------------ | | **Serum calcium** | ↑↑ (total & ionized) | | **Serum PTH** | **Inappropriately high** | | **Serum phosphate** | ↓ | | **Vitamin D (25-OH)** | Low/normal | | **Renal function** | Normal or ↓ | --- ## **B. Confirmatory Tests** ### **1) 24-hr Urinary Calcium** * **High or normal** in PHPT * **Low** in FHH → **key differentiator** ### **2) Imaging (for localization, NOT diagnosis)** * **Sestamibi Tc-99m scan** (best for adenoma) * Ultrasound neck * 4D CT (pre-operative planning) ### **3) Bone Density (DEXA)** * Low BMD, especially cortical bone (radius) --- # **6) Differential Diagnosis** | Condition | Differentiating Features | | ---------------------------------------------- | ----------------------------------------- | | **FHH (Familial Hypocalciuric Hypercalcemia)** | Low urinary calcium (<100 mg/day), benign | | **Tertiary hyperparathyroidism** | CKD history, very high PTH | | **Malignancy-associated hypercalcemia** | Low PTH, high PTHrP | | Vitamin D intoxication | High Ca + high phosphate | | Sarcoidosis | High Ca + high Vit D | | Thyrotoxicosis | Mild hypercalcemia, high T3/T4 | --- # **7) Management (Stepwise)** ## **A. Indications for Parathyroidectomy (Definitive Treatment)** (As per **Fourth International Workshop** & clinical guidelines) Surgery **recommended** when ANY of the following are present: 1. Serum calcium **>1.0 mg/dL above upper normal** 2. Age **<50 years** 3. Creatinine clearance **<60 mL/min** 4. Nephrolithiasis or nephrocalcinosis 5. Hypercalciuria (>400 mg/24 hours) 6. T-score ≤ −2.5 at any site 7. Fragility fracture 8. Vertebral compression fracture --- ## **B. Surgical Options** * Minimally invasive parathyroidectomy (single adenoma) * Bilateral neck exploration (hyperplasia) * Total parathyroidectomy + autotransplantation (selected cases) --- ## **C. Medical Management (when not surgical candidate)** ### **1) Cinacalcet** **Indication:** * Severe hypercalcemia when surgery not possible * Parathyroid carcinoma * Persistent disease post-surgery **Mechanism:** Calcimimetic → increases CaSR sensitivity → ↓ PTH secretion. **Dose:** * Start **30 mg twice daily**, titrate to calcium levels. **Side effects:** * Nausea, vomiting * Hypocalcemia * QT prolongation (rare) **Monitoring:** * Calcium levels 1 week after dose change * PTH every 3–6 months --- ### **2) Bisphosphonates** (Alendronate / Zoledronic acid) **Indication:** * Osteoporosis due to PHPT **Mechanism:** Inhibit osteoclast-mediated bone resorption. **Dose:** * **Alendronate 70 mg weekly** * **Zoledronic acid 5 mg IV yearly** **Side effects:** * Esophagitis (PO) * Acute-phase reaction (IV) * Hypocalcemia (rare) **Monitoring:** * BMD yearly * Calcium before each IV dose --- ### **3) Vitamin D Replacement** Correct deficiency to prevent worsening PTH: * **Cholecalciferol 1000–2000 IU/day** * Target 25-OH Vit D > 30 ng/mL **Important:** Correct slowly to avoid raising Ca too much. --- ### **4) Hydration + Lifestyle** * Drink ≥2.5–3L/day * Avoid thiazides * Avoid high-dose calcium supplements * Weight-bearing exercise * Avoid prolonged immobilization --- ## **D. Hypercalcemic Crisis – Emergency** **Severe Ca >14 mg/dL** Immediate steps: 1. **IV normal saline** 2. **IV furosemide** (after hydration) 3. **IV calcitonin** 4. **IV bisphosphonate (zoledronic acid)** 5. Dialysis if renal failure --- # **8) Complications** * CKD * Severe osteoporosis * Pathological fractures * Pancreatitis * Peptic ulcer * Parathyroid carcinoma (rare) * Cardiac arrhythmias * Hypercalcemic crisis --- # **9) Monitoring After Treatment** ### **If Surgery Done** * Serum calcium at 24 hours * PTH within 6 months * DEXA every 12–24 months ### **If Managed Medically** * Serum calcium every 6 months * PTH every 6–12 months * Vitamin D yearly * DEXA every 1–2 years * Renal ultrasound yearly --- # **10) Patient Counselling Points** * Stay well hydrated * Avoid thiazide diuretics * Avoid prolonged immobilization * Maintain Vit D in normal range * Watch for symptoms of hypercalcemia: * Polydipsia * Polyuria * Fatigue * Constipation * Explain that **surgery is curative** in most cases (95–98%) --- # **11) Tags (comma separated)** Primary Hyperparathyroidism, Hypercalcemia, PTH, Parathyroid Adenoma, Parathyroidectomy, Stones Bones Groans, Osteitis Fibrosa Cystica, Hyperparathyroid Crisis, Cinacalcet, Nephrolithiasis, Endocrinology, NEET PG Notes, ErrorOn Space Medical Notes --- If you want, I can now generate: ✅ **Case scenarios (10, 20, or 35 as needed)** ✅ **Hard MCQs with explanations** ✅ **HTML/PHP formatted version for your website** ✅ **Structured JSON meta (title, tags, slug, meta description)** Just tell me!

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