Hyperparathyroidism

• Primary hyperparathyroidism
  
  

• Overproduction of parathyroid hormone (PTH) with associated hypercalcemia

• Most frequent cause: single adenoma in 85% of cases

• Clinical: Bones (osteopenia, brown tumors), stones (renal calculi) and abdominal groans (ulcer disease)

• Laboratory: increased parathormone level with hypercalcemia is diagnostic of primary hyperparathyroidism

• Imaging of the parathyroid glands: radiolabeled technetium 99m sestamibi persists in adenomas on nuclear scans

• Brown tumors are more common than in secondary form

• Treatment: Symptomatic patients are usually treated by surgically removing abnormal gland(s)
  
  

• Secondary hyperparathyroidism
  
  

• Overproduction of PTH from extrinsic stimulation most frequently from chronic renal disease

• Most frequent cause: Parathyroid gland hyperplasia

• Clinical: Usually the symptoms of chronic renal failure predominate

• Laboratory:  Elevated PTH with low to normal serum calcium; phosphate levels may be high in renal disease, but low in vitamin D deficiency

• Imaging of the parathyroid glands: Imaging of parathyroid glands is not needed

• Extra-osseous calcification is more common in secondary hyperparathyroidism than in the primary form

• Treatment: medical management; vitamin D replacement, phosphate restriction or binding agents
  
  

• Tertiary hyperparathyroidism
  
  

  • Persistent hyperparathyroidism after correction of renal disease, such as with transplantation

• Most frequent cause: Autonomous overproduction by all 4 parathyroid glands follows secondary hyperparathyroidism; exact cause is unknown

• Clinical: Symptoms of hyperparathyroidism following renal transplant

• Laboratory: Elevated PTH with hypercalcemia and frequently hyperphosphatemia

• Imaging of the parathyroid glands: Imaging of parathyroid glands is not needed

• Treatment: Total or subtotal parathyroidectomy

Secondary Hyperparathyroidism. White arrows point to subperiosteal resorption along the radial (lateral) aspects of the middle phalanges of the index, middle and ring fingers, a finding virtually pathognomonic for hyperparathyroidism. The cortex appears spiculated. There is acro-osteolysis (yellow arrows) of several of the terminal phalanges. A small, lytic lucency in the head of the metacarpal of the middle finger represents a brown tumor.
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Secondary Hyperparathyroidism. White arrows point to subperiosteal resorption along the radial (lateral) aspects of the middle phalanges of the index, middle, ring and little fingers, a finding virtually pathognomonic for hyperparathyroidism. The cortex appears spiculated.