Parathyroid Disorders
CBL
Dr. Muhammad Imran
FCPS, FRCS,
MCPS-HPE
Learning Objectives
• Define hyperparathyroidism
• Discuss different types of hyperparathyroidism
• Describe investigations in a patient with
hyperparathyroidism
• Plan management of a patient with hyperparathyroidism
• Discuss management of hypoparathyroidism
Case-1
A 45-year-old female is referred to surgical OPD from
medical outpatient department with the investigations;
Serum calcium 11.2 mg/dl(Normal range 8.6 and 10.2
mg/dl)
Parathyroid hormone level is 300 pg/ ml (normal range 1065 pg/ ml).
Neck ultrasound: picture is shown;
Her presenting complaints, in medical OPD, were
psychological disturbances off and on and vague pain in legs
Questions
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•
•
•
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What is your provisional diagnosis?
What is differential diagnosis?
What are clinical presentations of this disease?
How can you localize this disease with investigations?
What should be the management plan?
What are known complications of treatment?
Provisional Diagnosis
•
Primary hyperparathyroidism
Differential Diagnoses of
Hypercalcemia
History
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Most patients are asymptomatic
•
Moans (CNS)
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Stones (renal)
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Abdominal groans
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Bones (pains and tumors (Osteitis fibrosa cystica)
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Family history (MEN?)
Physical Examination
Think about
malignancy
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Palpation of a parathyroid Adenoma
Investigations
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Electrolytes
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Albumin - for corrected serum calcium (CSC)
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CSC=[((4-patient albumin) * 0.8) + patient calcium]
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PTH
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PTH-related peptide
•
24-hours urine calcium
For familial
hypocalciuric
hypercalcemia
Neck Imaging
(Ultrasonography)
Technetium 99m Sestamibi
Most sensitive
Other Investigations (for persistent
or recurrent hyperparathyroidism)
•
CT especially 4D-CT
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MRI
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Selective venous sampling
Treatment
Surgery
Targeted approach
Conventional approach
Complications
Case-2
A 62-year-male was admitted in nephrology unit for dialysis
and management of electrolyte. His investigations reveal;
Serum calcium 7.9 mg/dl(Normal range 8.6 and 10.2 mg/dl)
Parathyroid hormone level is 150 pg/ ml (normal range 1065 pg/ ml)
Questions
• What is your provisional diagnosis?
• How the management would be different from case-1?
Provisional diagnosis
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Secondary hyperparathyroidism
Management
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Initially conservative
•
Surgery in persistent cases
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Total parathroidectomy with or without
autotransplantation of 50 mg parathyroid tissue
Case-3
A 19-year-old female, after total thyroidectomy, develops
paresthesia in her fingers. Her serum calcium level is 7.2 mg/
dl on first postoperative day.
Questions
•
•
•
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What is your diagnosis?
What are different signs for hypocalcemia?
What is significance of surgical anatomy?
How will you manage this case?
Diagnosis
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Hypoparathroidism (postoperative complication)
Signs of hypoparathyroidism
Chvostek
Trousseau
Surgical anatomy
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Inferior parathyroid and thymus from 3rd pouch
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Superior parathyroid from 4th pouch
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Vascular supply is important (Inf. thyroid)
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Position is variable esp. inf. Parathyroid
Management
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10ml of 10% Calcium gluconate IV
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Oral calcium and Vit D
Questions?
You are able to;
• Define hyperparathyroidism
• Discuss different types of hyperparathyroidism
• Describe investigations in a patient with
hyperparathyroidism
• Plan management in a patient with hyperparathyroidism
• Discuss management of hypothyroidism
Thank you