Mcphs Parathyroid Disease

Front 1

This is the single most important regulator of PTH is ?

Back 1

Serum ionized calcium

Front 2

What are two other things, besides calcium, that contribute to parathyroid hormone regulation?

Back 2

1. Vitamin D

2. Serum Phosphate

Front 3

What are the three mechanisms by which parathyroid hormone causes an increase in calcium?

Back 3

1. Prolonged secretion of PTH increases the number and activity of osteoclasts

2. PTH stimulates the kidney to increase calcium and decrease phosphate resorption

3. PTH stimulates the synthesis of Vitamin D which induces an increase in intestinal calcium absorption.

Front 4

This is more frequent in people over 50

Women are more affected than men

Hypercalcemia of malignancy is seen with this

Back 4

Hyperparathyroidism

Front 5

The hypercalcemia of malignancy associated with hyperparathyroidism has two main factors, what are they?

Back 5

1. Tumors secrete PTH related protein (PTHrP)

2. Increase incidence associated with breast cancer and non-melanoma skin cancer - basal and squamous cell cancer

Front 6

This is when there is excessive secretion of PTH by the parathyroid gland - labs will show increased PTH and calcium.

Back 6

Primary hyperparathyroidism

Front 7

What are the five main causes of PTH hypersecretion?

Back 7

1. Parathyroid gland adenoma

2. Hyperplasia of the parathyroid glands

3. Parathyroid cancer

4. Familial

5. Secondary to lithium therapy

Front 8

Causes of hypersecretion of PTH from the parathyroid hormone can be secondary to what drug therapy?

Back 8

Lithium

Front 9

This is a cause of primary hyperparathyroidism. It accounts for approximately 80-90% of cases, the size of the adenoma correlates with the serum PTH level.

Back 9

Parathyroid gland adenoma

Front 10

This is a cause of primary hyperparathyroidism. It can involve one gland or all four, may develop independently or in response to chronic hypocalcemia.

Back 10

Hyperplasia of the parathyroid glands

Front 11

This accounts for less than 1 % of all primary hyperparathyroidism cases. There is a higher incidence when hyperparathyroidism occurs before the age of 30.

Back 11

Parathyroid cancer

Front 12

This is a familial disorder that causes primary hyperparathyroidism. It is associated with parathyroid hyperplasia, pancreatic tumors, and pituitary adenomas.

Back 12

MENI

Front 13

This is a familial disorder that causes primary hyperparathyroidism. It is associated with asymmetric parathyroid hyperplasia and medullary thyroid cancer.

Back 13

MEN2A

Front 14

This is a familial disorder that causes primary hyperparathyroidism. It is caused by a mutation of the calcium sensing receptors that shift to a higher set point for calcium.

Back 14

Familial hypocalciuric hypercalcemia

Front 15

Associated with primary hyperparathyroidism. This is seen in approxmiately 15-60% of patients taking this medication. Shifts the set point for calcium to a higher threshold. Often resolves when lithium is withdrawn.

Back 15

Lithium therapy

Front 16

This is hyperparathyroidism associated with chronic kidney disease (hypocalcemia, hyperphosphatemia, and Vitamin D deficiency), Vitamin D deficiencies, The primary defect is not with the parathyroid gland.

Back 16

Secondary hyperparathyroidism

Front 17

This is hyperparathyroidism, under chronic stimulation as seen with chronic kidney disease, the parathyroid glands hypertrophy and continue to secrete excess PTH even after correcting underlying calcium, most common in renal transplant patients.

Back 17

Tertiary Hyperparathyroidism

Front 18

These are usually not palpable in the physical exam?

Back 18

Parathyroid adenomas

Front 19

Approximately 50% of parathyroid cancers are associated with?

Back 19

a palpable mass

Front 20

This is a clinical manifestation of hyperparathyroidism. It can be asymptomatic, but it can also manifest as via thirst, annorexia, nausea, vomiting, constipation, fatigue, weakness.

Band Keratopathy: Calcium precipitates in the corneas

Calciphylaxis: Calcium precipitates in soft tissue.

Back 20

Hypercalcemia

Front 21

This is a clinical manifestation of hyperparathyroidism. It can be seen as depression, psychosis, personality changes, confusion, hallucinations, paresthesias, decreased DTRs.

Back 21

Psychiatric/Neurologic manifestations of hyperparathyroidism

Front 22

What are the gastrointestinal manifestations of hyperparathyroidism?

Back 22

Constipation, nausea/vomiting, abdominal pain

Front 23

What are the clinical manifestations of hyperparathyroidism in the musculoskeletal system?

Back 23

Decreased bone mass

Osteitis Fibrosa Cystica

Front 24

This is a musculoskeletal manifestation of hyperparathyroidism that is a loss of corticol bone predominately from the long bones. It is associated with bone pain, arthralgias, pathologic long bone fractures.

Back 24

Decreased bone mass

Front 25

This is a clinical manifestation of hyperparathyroidism that is an increased osteoclastic resorption of bone, pentrabicular fibrosis and cystic brown tumors. With X-Rays pathologic fractures, mottling of the skull "salt and pepper" appearance.

Back 25

Osteitis Fibrosa Cystica

Front 26

What is the most common presenting renal presentation of hyperparathyroidism?

Back 26

Nephrolithiasis

Front 27

Besides nephrolithiasis, what else manifests in the renal system in hyperparathyroidism?

Back 27

Hypercalcemia induced nephrogenic diabetes insipidus - polyuria and polydipsia

Front 28

What will the diagnostic tests show when looking for hyperparathyroidism?

Back 28

Hypercalcemia - serum total calcium >10.5mg/dL

Elevated PTH

Front 29

Apart from hypercalcemia and elevated PTH, what else is associated with the lab findings for hyperparathyroidism?

Back 29

Elevated urine calcium

Hypophosphatemia - serum phosphate <2.5mg/dL

Elevated urine phosphate

Neck US or radionuclide imaging to identify adenoma or gland hyperplasia

Elevated alkaline phosphatase if bone disease is present

Check serum 25-OH vitamin D level

Front 30

People affected by this typically have high normal or mildly elevated calcium levels with PTH levels that are inappropriately normal or only slightly elevated.

Back 30

Familial hypocalciuric hypercalcemia

Front 31

How do you test for familial hypocalciuric hypercalcemia?

Back 31

Check a 24 hour urine calcium excretion - Low in FHH, high in PHP

Front 32

With this you will see elevated PTH, normal to low calcium, vitamin D deficiency, and kidney disease/failure. Must check vitamin D level and BUN/creatinine, serum phosphate.

Back 32

Secondary hyperparathyroidism

Front 33

Mild asymptomatic primary hyperparathyroidism may only require ?

Back 33

1. Close follow up - check creatinine to make sure kidneys are working properly

2. Patient education

Front 34

What are three things to tell all patients dealing with hyperparathyroidism?

Back 34

1. adequate hydration

2. moderate intake of calcium

3. avoid thiazide diuretics, large doses of vitamin A, calcium containing antacids or supplements

Front 35

This is indicated for patients with symptomatic parathyroidhormone disease with an adenoma or with significant hyperplasia?

Back 35

Surgical treatment

Front 36

What are the other indications for surgical tx of hyperparathyroidism?

Back 36

Age < 50 years

Serum calcium >1mg/dL above the upper limit of normal

Patients for whom medical follow up is not possible

Marked hypercalciuria (>400mg daily)

Reduction in bone mineral density at any site to a T score of <2.5

Decrease in Calcium:Creatinine (ClCr) to 70% of normal

Pregnancy

Front 37

What are the surgical complications associated with hyperparathyroid surgery?

Back 37

1. Post operative hypocalcemia - parasthesias - most common in first 24 hours

Treatment is calcium carbonate

2. Hungry bone syndrome
Most common approximately 1 week after surgery, marked by profound hypocalcemia and increased PTH, treat with calcium and vitamin D

Front 38

What is a medical treatment that can be used for hyperparathyroidism patients, it inhibits bone loss associated with PHP?

Back 38

Bisphosphonates - inhibits bone loss associated with PHP; cause a decline in calcium levels over days. Use IV pamidronate and Zoledronate. PO alendronate has been shown to increase bone density in the lumbar spine and hip.

Front 39

This is a medical treatment that can be used for hyperparathyroidism. It lowers PTH and calcium levels by enhancing the sensitivity of the calcium sensor receptors to calcium.

Back 39

Calcimimetics - Cinacalcet

FDA approved for the tx of secondary hyperparathyroidism in patients with CKD on dialysis and for patients with parathyroid carcinomas.

Front 40

How do you TX Vit D deficiency in secondary hyperparathyroidism?

Back 40

Ergocalciferol (D2) 50,000 IU weekly or monthly - replace unitl 25(OH(D level is >30ng/ml

Front 41

How do you TX secondary hyperparathyroidism in chronic kidney disease?

Back 41

Maintain PTH levels based on stage of CKD - typically correct hyperphosphatemia first then control the calcium and finally correct for vitamin D.

IV vitamin D therapy (calcitrol) to patients on dialysis to suppress parathyroid hyperplasia

Cinacalcet for patients on dialysis - dose reduction dependent reduction in PTH

Front 42

What is involved in the follow up TX of someone dealing with parathyroid disease?

Back 42

check serum calcium level every six months

check creatinine every 6-12 months

check bone density (distal radius, hip and spine) every 1-2 years.

Front 43

This is inappropriate, low secretion of PTH for a given level of ionized calcium.

Back 43

Hypoparathyroidism

Front 44

This is when there is an inappropriately low secretion of PTH for a given level of ionized calcium.

Back 44

Hypoparathyroidism

Front 45

What are the five causes of hypoparathyroidism?

Back 45

1. Surgical - Most common after thyroidectomy

2. Damage from heavy metal or iron deposits

3. Magnesium deficiency - prevents secretion of PTH

4. Polyglandular Autoimmune Syndrome - Mucocutaneous candidiasis, hypoparathyroidism, adrenal insufficiency

5. Congenital hypoparathyroidism

Front 46

What are the symptoms associated with acute hypoparathyroidism?

Back 46

Tetany
Tingling of circumoral area, hands and feet
Carpopedial spasm
Hyperactive DTRs
Muscle cramps
Irritability
Convulsions

Front 47

What are the symptoms associated with chronic hypoparathyroidism?

Back 47

Lethargy
Personality changes
Anxiety
Cataracts
Parkinsonism
Mental Retardation

Front 48

This is an adduction of the thumb, flexion of the metacarpal joints, and flexion of the wrist seen with acute hypoparathyroidism

Back 48

Carpopedal spasms

Front 49

This is an ipsalateral facial muscle contraction caused by tapping of the facial nerve 2cm in front of the ear. This sign is associated with hypoparathyroidism.

Back 49

Chvostek's sign

Front 50

This is associated with hypoparathyroidism and is a carpal spasm after application of a cuff 20mmHg above systolic BP for 3 minutes.

Back 50

Trousseau's Phenomenon

Front 51

What are the dermatologic manifestations of hypoparathyroidism?

Back 51

Dry brittle nails

Dry skin

Loss of hair (eyebrows)

Impetigo herpetiformis - form of pustular psoriasis in a pregnant female with hypocalcemia

Front 52

What is the classic laboratory presentation of hypoparathyroidism?

Back 52

Low serum calcium

Low PTH

High serum phosphate

Low urinary calcium

Alkaline phosphatase normal

Front 53

What are the EKG findings with hypoparathyroidism?

Back 53

Prolongation of the QT interval

T wave inversion

Front 54

With hypoparathyroidism what is something that must be checked?

Back 54

Check serum magnesium level - hypomagnesemia and hypocalcemia are often found together.

Magnesium deficiency prevents the secretion of PTH

Hypomagnesemia can exacerbate hypocalcemia

Front 55

This is associated with hypoparathyroidism. This is a major binding protein of calcium.

Back 55

Hypoalbuminemia. Albumin is a major binding protein of calcium.

Front 56

This produces a low total serum calcium concentration because of the reduction in the bound fraction of calcium but the ionized calcium is normal.

Back 56

Low albumin

Front 57

How do you correct for hypoalbuminemia?

Back 57

By either measuring ionized calcium or using the calculation.

Corrected serum calcium = measured serum calcium (total) + (.8 X [4-measured serum albumin])

Front 58

What are the five steps in Tx acute hypoparathyroidism?

Back 58

1. Secure the airway

2. IV calcium gluconate or calcium chloride

3. Oral Calcium

4. Oral Vitamin D

5. Correct any underlying hypomagnesemia

Front 59

What is the Tx for chronic hypoparathyroidism?

Back 59

Includes both oral calcium and Vitamin D.

Maintain serum calcium between 8-8.6mg/dL

Front 60

This is a cluster of inherited disorders. Elevated PTH, low calcium, high phosphate, caused by a decreased end organ response to PTH.

Back 60

Pseudohypoparathyroidism

Front 61

What is the prognosis with hypoparathyroidism?

Back 61

Prognosis is good if discovered and treated early

Dental changes, cataract formation and brain calcifications are permanent

Periodic serum levels for monitoring