"Bones, moans and stones" is the classical description of hyperparathyroidism but such clear cases are uncommon in the Wesren world.
Patients with primary hyperparathyroidism may:
- present with symptoms of hypercalcaemia or PTH excess
- be asymptomatic (hypercalcaemia detected incidentally) - more commonly seen
Symptomatic hypercalcaemia:
- in the Western world this variant accounts for only 20-30% of patients while in the developing countries most patients still present with symptomatic primary hyperparathyroidism
- symptoms may include:
- renal manifestations - nephrolithiasis (most common), polyuria, and renal insufficiency
- bone pathology
- fragility fractures
- low bone mineral density, with preferential bone loss at sites rich in cortical bone
- osteitis fibrosa cystic - classical primary hyperparathyroid bone disease characterised by generalised demineralisation of the skeleton, subperiosteal bone resorption, and the development of bone cysts
- gastrointestinal symptoms - nausea, peptic ulcer disease, constipation, pancreatitis (uncommon)
- neurospsychiatric disturbances - depression, lethargy, and decreased cognitive and social function which may progress into psychosis and coma in severe hypercalcaemia,
- gout and pseudogout – may be associated with primary hyperparathyroidism
- cardiovascular manifestations
- seen in severe primary hyperparathyroidism
- includes left ventricular hypertrophy, cardiac calcification, conduction abnormalities, endothelial dysfunction, and a shortened QT interval.
Asymptomatic hypercalcaemia
- diagonsed during routine screening or during assessement for low bone mineral density
- patienta may have non specific symptoms of mild hypecalcaemia e.g. - fatigue, mild depression or malaise
Normocalcaemic hyperparatyroidism
- patients with normal serum calcium but elevated PTH
- may be identified during evaluation of osteoporosis or a fragility fracture (a raised PTH is identified on further assessment of the osteoporosis)
- vitamin D inadequacy and renal impairment which present with increased PTH values and normal serum calcium should be excluded
Features attributable to hypercalcaemia may be evident in primary and tertiary hyperparathyroidism.
- in secondary hyperparathyroidism, the clinical picture may be complicated by hypocalcaemia. In chronic renal failure, co-existent osteomalacia results in renal osteodystrophy
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