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PubMedDate not supplied

New onset of neuropsychiatric symptoms in the elderly: possible primary hyperparathyroidism.

Primary hyperparathyroidism is a disorder of calcium homeostasis that occurs most commonly in older adults. Resultant hypercalcemia may be accompanied by neuropsychiatric symptoms, ranging from mild depression and cognitive changes to extreme agitation and psychosis. Surgical intervention almost invariably reverses these symptoms. The authors reviewed the importance of considering this diagnosis in the setting of neuropsychiatric symptoms in the elderly and reported on a 63-year-old man with mild hypercalcemia and a new onset of psychosis.

Humans↗
PubMed2004

Novel intronic mutation of MEN1 gene causing familial isolated primary hyperparathyroidism.

Primary hyperparathyroidism may occur as part of hereditary syndromes, including multiple endocrine neoplasia types 1 and 2A (MEN1 and MEN2A), hyperparathyroidism-jaw tumor syndrome, and the familial isolated hyperparathyroidism (FIHP). It is unclear whether FIHP corresponds to a different genetic entity or a variant of MEN1 (or hyperparathyroidism-jaw tumor syndrome). We report a patient and 11 family members with FIHP in whom we identified a heterozygous G-to-A mutation at nucleotide 7361 of tumor suppressor MEN1 gene. This mutation is located in the first base of intron 9 (IVS9 + 1 G>A). All the family members with hyperparathyroidism were heterozygous for the intronic mutation. In vitro studies were performed in COS cells transfected with minigenes carrying the coding regions spanning exon-intron 9 and 10 with the mutant and the wild-type sequences. RT-PCR analyses showed an abnormal mRNA of greater size (829 bp) in the mutated MEN1 gene than the normal transcript (629 bp). The longer PCR product includes the exon 9, the unspliced intron 9, and part of exon 10. RT-PCR of MEN1 mRNA from patient's blood confirmed the existence of unspliced intron 9 in mature mRNA. In summary, we report a case of FIHP associated with a new intronic heterozygous germline mutation (IVS9 + 1 G>A) of MEN1 gene. This mutation produces an aberrant splicing of mRNA that could lead to a truncated protein, without activity, explaining the clinical picture of this patient and his family.

Adenine↗
PubMed2000

Augmentation of central arterial pressure in mild primary hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is associated with increased cardiovascular risk, although the mechanisms involved remain unclear. Recent evidence has shown increased pulse pressure to be a powerful predictor of cardiovascular events. As increases in pulse pressure are due largely to arterial stiffening, we measured arterial stiffness in 21 subjects with PHPT (18 women and 3 men; 46-71 yr old) and 21 age- and sex-matched healthy controls using pulse wave analysis, a technique that measures peripheral arterial pressure waveforms and generates corresponding central aortic waveforms. This allows determination of the augmentation of central pressure resulting from wave reflection and augmentation index, a measure of vessel stiffness. Metabolic parameters were also measured. The serum calcium level among PHPT subjects was (mean +/- SD) 2.74+/-0.14 mmol/L. pulse wave analysis showed that both augmentation and the augmentation index were significantly higher in the PHPT group vs. controls [16+/-5 vs. 10+/-4 mm Hg (P < 0.001) and 36+/-9% vs. 25+/-6% (P < 0.001)] despite comparable brachial systolic pressures between groups (136+/-13 vs. 134+/-18 mm Hg). Patients with PHPT had higher fasting serum insulin levels [median (range), 15.8 (7.4-39.4) vs. 11.6 (5.1-23) mU/L; P < 0.05] and triglyceride (1.6+/-0.6 vs. 1.2+/-0.4 mmol/L; P < 0.05), but lower high density lipoprotein cholesterol (1.4+/-0.4 vs. 1.6+/-0.3 mmol/L; P < 0.05). These data indicate that subjects with mild PHPT (calcium, <3.0 mmol/L) have increased arterial stiffness, as evidenced by higher augmentation of central aortic pressures. Enhanced vessel stiffness may arise from a combination of structural and functional vascular changes due to hypercalcemia and/or metabolic abnormalities. Increased vascular stiffness in subjects with PHPT may account in part for the increased cardiovascular risk in this group.

Aged↗
PubMed1999

[A Scandinavian multicenter study will investigate the question: surgery or not in mild primary hyperparathyroidism?].

Primary hyperparathyroidism is a common endocrine disease particularly prevalent among elderly women. A majority of these patients diagnosed today are mildly hypercalcaemic, and many seem to lack manifest symptoms or complications. In such cases, conservative follow-up rather than parathyroid surgery may be suggested. However, long-term follow-up may entail costly investigations and be difficult to accomplish. Moreover, conservative follow-up is associated with a risk of subsequent complications or even premature death due to cardiovascular disorders. A Scandinavian multicentre study has been initiated to assess survival, morbidity and quality of life in surgically vs. conservatively treated patients.

Aged↗
PubMedDate not supplied

Color-Doppler in the imaging work-up of primary hyperparathyroidism.

Primary hyperparathyroidism (PHP) is a rare disease that must be suspected in all the cases of recurrent calcium nephrolithiasis, and that may be totally corrected by surgery. The imaging techniques permit to locate the hyperplastic gland or adenoma before intervention, but their usefulness in patients without a history of previous neck surgery is still debated. Several imaging techniques have been proposed with the aim of locating parathyroid hyperfunctioning glands, including high resolution sonography (US) with color-Doppler (CD), scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI). We report here a case of recurrent calcium oxalate nephrolithiasis sustained by PHP, which demonstrates how US coupled with CD and echocontrast enhancement is useful in the preoperative location of parathyroid glands. US is the first choice technique in the evaluation of PHP because it is less expensive and useful in detailing lesions of the neck when carried out by a skilled operator. CD should be regarded as a useful complement of US enhancing its sensitivity (80 vs 90%) especially in the cases of associated thyroid gland diseases. Tc-99m SESTAMIBI scintigraphy coupled with MRI is mandatory in high risk surgical patients, namely in those undergoing repeated neck surgery. In conclusion, considering that surgeon must explore all the four parathyroid glands (because of the possibility of multiple adenomas or hyperplasia) a well definite location of the adenomatous lesion may reduce the risks and the time of intervention, and allow the use of alternative procedures, such as videoscopic surgery. On this view and in terms of economy, only US and CD coupled with Tc-99 SESTAMIBI scintigraphy should be considered before surgery.

Adenoma↗
PubMedDate not supplied

[Primary hyperparathyroidism].

Primary hyperparathyroidism is a hormonal disease that is more and more frequent and is often manifested exclusively by an increase in calcium levels in the serum. After examining the main anatomopathological and clinical characteristics of the disease, the authors present their experience in its diagnosis and surgical treatment. They suggest that cervical exploration with removal of the adenomas and hyperplastic glands in both asymptomatic and highly symptomatic patients is strongly advised. Since it is already possible to obtain an early diagnosis of the disease thanks to multicanal hematochemical equipment, the Authors conclude that in the near future, studies on cellular receptors for calcium will allow new therapeutic treatments to be applied.

Adolescent↗
PubMed2000

[Multifocal osteolysis as a result of delayed diagnosis for primary hyperparathyroidism].

Primary hyperparathyroidism caused by solitary adenomas occurs rarely (especially in children and adolescents). The clinical manifestations are usually subtle and that is why the mentioned disorder is usually late diagnosed and as an effect--late treated. We present the case of a 17 year old girl, an ambulatory patient who had been "observed" for over 12 months because of persistent ostealgia. She had not been properly diagnosed. The first diagnostic investigation of calcium and phosphate balance was provided only when multifocal osteolysis of tibias, hip and metacarpal bones was detected and biopsy of the mentioned osteolytic lesions was done. After the admission to The Department of Pediatrics, Endocrinology and Disease of Adolescents: Ca 3.02-3.06 mmol/l, PO4- 0.32-0.62 mmol/l, ACP 19.4 U/l, ALP 864 U/l, PTH 770 pg/ml [normal values: 10-70]. Densitometry findings: BMD (Neck[L]) 0.636 g/cm2, BMD (Neck[R]) 0.722 g/cm2. The parathyroid adenoma was removed after the exploration and localization with MIBI99mTc (scintigraphy). Clinical diagnosis was verified by histologic findings. 5 months after: BMD (Neck[L]) 0.850 g/cm2, BMD (Neck[R]) 0.741 g/cm2, calcemia 2.38 mmol/l, phosphatemia 1.14 mmol/l, ACP 6.2 U/l, ALP 159 U/l. Radiograms show evident improvement of bone tissue structure.

Adenoma↗
PubMed2000

[Primary hyperparathyroidism].

Primary hyperparathyroidism is the third most frequent endocrine disorder. The condition required for diagnosis is inappropriately elevated secretion of parathyroid hormone (PTH) with respect to calcemia. Most often, the disease is due to a parathyroid adenoma, i.e. a monoclonal benign parathyroid tumor, less often to a parathyroid hyperplasia. The main tumorogenic mechanisms currently proposed are a DNA rearrangement in the PTH locus (transposition of the PTH promoter upstream to Cyclin D1/PRAD 1 gene) and a mutation of the gene responsible for multiple endocrine neoplasia type I. The clinical presentation has strikingly evolved towards a milder, asymptomatic form, frequently diagnosed on systematic screenings. Though the mechanism of hypercalcemia is better understood, several hypothesis are still being considered about the regulation of tumoral PTH secretion: the role of the expression of calcium-receptor in parathyroid gland cells, vitamin D receptor and estrogen receptor polymorphisms, etc. Surgery is still advised for symptomatic forms of the disease, either because of a bone involvement, or because of an evolutive nephrolithiasis. In the near future, the new calcium-receptor agonists could be a relevant therapeutic approach.

Humans↗
PubMed2000

[Diagnosis and surgical treatment of primary hyperparathyroidism].

Primary hyperparathyroidism (HPP) is increasingly being recognized because of the widespread use of multiphasic screening for hypercalcemia, in patients without clinical signs. Each year develop 100,000 new cases in the United States, females/males 5:2; the peak of incidence is in V-VI degrees decade. We analyze our patients from November 1975 to July 2000. We have performed 112 parathyroidectomy for HPP, 84 females and 28 males, median age 57.5 years. We have examined the surgical options, the value of PTH, calcium, and the number of pathological glands. The Authors discuss the invasive or non-invasive procedures and the surgical treatment.

Adolescent↗
PubMed2002

[Selective parathyroidectomy with unilateral cervical exploration for primary hyperparathyroidism].

Primary hyperparathyroidism (pHPT), is caused in over 90% of the cases by a single parathyroid adenoma. Preoperative diagnostic imaging techniques, in particular dual phase scintigraphy with SestaMIBI/TC99 and high frequency probe ecography, are able to pinpoint it 90% of the time. These are the two cornerstones of modern pHPT surgery, which has witnessed the passage from cervical exploration of all the most common parathyroid glandular sites to a more carefully targeted, restricted approach in the side of the neck where the adenoma is suspected to be. This is how selective parathyroidectomy with unilateral cervical exploration and, recently, mini-invasive parathyroidectomy, came into being. Between 1996 and 2001, in the Otolaryngology Department of S. Maria della Misericordia Hospital in Udine, 39 patients affected by pHPT, half of whom (49%) were asymptomatic, underwent selective parathyroidectomy with unilateral cervical exploration. The object of this paper was to evaluate the efficacy of this surgical technique by comparing the pre- and post-operative calcaemia and parathormone levels. The normalization of these parameters, and particularly of the latter, was considered indicative of successful treatment. All the postoperative calcaemia levels were normal, while elevated parathormone levels persisted in only 2 cases (5%). Our statistics showed a 95% efficacy for selective parathyroidectomy, a result that is comparable to the percentages described in the literature. There were, furthermore, no significant peri- or postoperative complications in any of the cases. These observations, together with the brief operating times required for the procedure (20-25 minutes on average) and the low cost of the material employed, enable us to conclude that selective parathyroidectomy with unilateral cervical exploration continues to hold its own as a valid option in the present scenario of surgical pHPT treatment, also in consideration of the fact that it does not present the rigid inclusion criteria characteristics of mini-invasive techniques.

Adult↗
PubMed2003

[Osteoporosis associated with primary hyperparathyroidism].

Primary hyperparathyroidism (pHPT) is cited as one of diseases which cause secondary osteoporosis and predominantly affects cortical bone. This disease occurs frequently during the postmenopausal period. Parathyroidectomy (PTX) is the only option available for the radical cure of pHPT and brings about marked increase in bone mass even in postmenopausal women. On the other hand, this disease is now recognized as a disorder with few overt manifestations, presenting as asymptomatic hypercalcemia. Even in these cases, a considerable increase in bone mass can be obtained by PTX. Bisphosphonate as well as estrogen and raloxifene are also reported to increase bone mass in elderly pHPT. patients. These drugs are considered as alternative therapy for mild pHPT patients who have many complications and/or are unfit for surgery.

Diphosphonates↗
PubMed1992

[Primary hyperparathyroidism].

Primary hyperparathyroidism due to a solitary adenoma of the right inferior parathyroid gland was diagnosed in a 60 year old female, presenting a 4 year complaint of progressive disabling bone and joint pain. The diagnostic follow-up used in this case, including the imaging techniques, the clinical features and the medical and surgical management are presented and discussed.

Adenoma↗
PubMed1989

Primary hyperparathyroidism.

Primary hyperparathyroidism is a pathological entity due to excessive secretion of parathormone from a single or multiple parathyroid glands. The biochemical hallmark of this disorder is an elevated serum calcium. The relationship of the parathyroid glands with the thymus gland in fetal development accounts for the occasional aberrant location of the parathyroids. By utilizing computed tomography or nuclear scanning or both preoperatively, the surgeon can isolate the hyperfunctioning adenoma and resect it, thus minimizing potential complications.

Humans↗
PubMed1994

Primary hyperparathyroidism.

Primary hyperparathyroidism is not rare. It is particularly common after the age of 50 and may affect up to 3% of postmenopausal women. It is commonly found as a result of blood tests performed for other reasons and is therefore often asymptomatic. Surgical treatment is recommended for patients with renal stone disease, plasma calcium above 3 mmol/L and accelerated bone loss (e.g., bone density < 3 standard deviations below the young normal mean). There is considerable debate about whether mild asymptomatic disease should be treated, but if there is rapid bone loss, either surgical or medical therapy with hormones or bisphosphonates is indicated.

Aging↗
PubMed1994

[What is new in surgery for primary hyperparathyroidism?].

Primary hyperparathyroidism is being increasingly recognized because of the widespread availability of biological screening, thus explaining that one third of the patients are nowadays asymptomatic at diagnosis. Initially based on the hypercalcemia-hypophosphoremia syndrome, its diagnosis is now depending upon biological measurements of AMPc, intact (1-84) parathyroid hormone and dynamic tests such as the oral calcium-loading test. A controversial issue is the use of sophisticated imaging methods (ultrasonography, computed tomography, thallium-technetium scanning, magnetic resonance imaging and more infrequently venous catheterization with blood sampling) to localize the abnormal parathyroid glands, which are clearly inferior to surgery with a 95% success rate. The lesions include single adenoma in 80%, multiple adenomas in 5%, cancer in 1% and hyperplasia in 14% of the cases. Moreover, among the majority of seemingly sporadic hyperparathyroidism, about 10% of the cases appear to be part of a multiple endocrine neoplasia which is frequently misdiagnosed or lately recognized. The questions remain (as to) whether the surgical strategy should be revisited and whether intraoperative histopathological examination of the removed abnormal gland is still needed to ensure excellence in the management of hyperparathyroidism. However, since its initial description in the early 80s, the concept of unilateral cervical exploration directed by an accurate localization study and intraoperative measurements of intact hormone could become in the future the standard approach for surgical treatment in more than half of the patients.

Humans↗
PubMed1993

Prediction of changes in bone density after operation for primary hyperparathyroidism.

Primary hyperparathyroidism (pHPT) is associated with osteopenia. However, the individual variation in recovery in bone mass after surgery is large. Therefore, modes of prediction of the increase in bone mass after parathyroid surgery were investigated. Preoperatively and at one year after surgery bone mineral content (BMC) in the distal radius was measured with single photon absorptiometry technique in 40 patients with pHPT. Serum levels of calcium, intact parathyroid hormone (PTH), alkaline phosphatase, osteocalcin and Vitamin D metabolites were also determined. Preoperatively, Z-score of BMC was -0.85 +/- 1.20 SD below the normal mean. There was a modest association between BMC and serum levels of osteocalcin (r = -0.34; P < 0.05), and dihydroxycholecalciferol (r = -0.35; P < 0.05). At one year after surgery, mean BMC increased by 2% (P < 0.05), but with a wide dispersion. Preoperative Z-score of BMC correlated with the relative change in BMC (r = -0.33; P < 0.05). An increase in BMC with 95% confidence was evident in 10 of the patients. None of these patients had a preoperative Z-score of BMC above the mean expected for age and sex. We conclude that the increase in bone mass after surgery for pHPT is small and evident only in a portion (approximately 25%) of patients. Hence, a decrease in bone mass should not be a major indication for surgery in pHPT.

Bone Density↗
PubMed1994

Relationship between abnormal regulation of cytoplasmic calcium and elevated blood pressure in patients with primary hyperparathyroidism.

Primary hyperparathyroidism (HPT) is characterised by a defective calcium sensitivity of the parathyroid glands. HPT is, furthermore, associated with a high prevalence of hypertension. In the present study BP was measured before operation, during surgery and after operation in 42 HPT patients and in 15 control subjects operated for non-toxic goitre. Parathyroid tissue was removed from all patients and the concentration of cytoplasmic calcium [Ca2+]i was determined in vitro in dispersed single cells by means of microfluometry at extracellular calcium concentrations of 0.5 mM and 3.0 mM. The SBP levels were found to be raised both before (158 +/- 23 (SD) mmHg vs. 144 +/- 24 mmHg in controls, P < 0.05), during surgery (maximal level 167 +/- 22 mmHg vs. 146 +/- 16 mmHg in controls, P < 0.01) and after operation (maximal level 180 +/- 26 mmHg vs. 148 +/- 20 mmHg in controls, P < 0.001) in the HPT subject when compared with controls. SBP during surgery was found to be related to the in vitro measured [Ca2+]i in the parathyroid cells at 3.0 mM extracellular calcium concentration or to the ratio of [Ca2+]i at 3.0 mM-0.5 mM (r = -0.25 and -0.27, respectively; P < 0.05). The degree of suppression of PTH release in vitro at 3.0 mM extracellular calcium was found to be related to both systolic and diastolic BP (r = 0.57 and r = 0.53, respectively; P < 0.05) before surgery. In conclusion, BP was found to be raised in HPT patients both before operation as well as during surgery and after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1996

Delayed diagnosis of juvenile primary hyperparathyroidism.

Primary hyperparathyroidism (PHP) is most common in adults in the fifth and sixth decades of life, but is seen infrequently in adolescence and is extremely rare in children under the age of 14 years. We report the case of a young female whom we suspect had PHP from the age of 6 years. This condition remained undiagnosed for the next 11 years in spite of repeated hospital admissions. The hypercalcaemia which was initially labelled as 'idiopathic' was eventually found to be secondary to a parathyroid adenoma, which was treated successfully by surgery. The case illustrates two important advances: (1) in parathyroid hormone measurement with a new sensitive immuno-radiometric assay, and (2) in the development of radionuclide scanning for localization of parathyroid adenoma(s). No case of hypercalcaemia should be labelled as 'idiopathic' or left unexplained without a detailed exploration of the neck to exclude PHP arising from a parathyroid adenoma.

Adenoma↗