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Calcium Homeostasis & Parathyroid Disorders

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    CALCIUM HOMEOSTASISCALCIUM HOMEOSTASIS& PARATHYROID& PARATHYROID

    DISORDERSDISORDERS

    DR. MAHMUDUL HUQUEDR. MAHMUDUL HUQUE

    HOLY FAMILY RED CRESCENTHOLY FAMILY RED CRESCENTMEDICAL COLLEGEMEDICAL COLLEGE

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    Calcium HomeostasisCalcium Homeostasis

    calcium homeostasiscalcium homeostasis is theis themechanism by which the bodymechanism by which the body

    mainta

    ins

    adequate calcium level

    s.ma

    inta

    ins

    adequate calcium level

    s.Derangements of this mechanismDerangements of this mechanism

    lead to hypercalcaemia orlead to hypercalcaemia orhypocalcaemia, both of which canhypocalcaemia, both of which can

    have important consequences forhave important consequences forhealth.health.

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    Normal range:Normal range:

    9910.510.5 mg/dL ormg/dL or2.22.22.62.6 mmol/Lmmol/L

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    Corrected Ca levelCorrected Ca level

    Corrected calcium (mg/dL) =Corrected calcium (mg/dL) =measured total Ca (mg/dL) + 0.8 Xmeasured total Ca (mg/dL) + 0.8 X

    (4.0(4.0 --s

    erum albumi

    n [g/dL]s

    erum albumi

    n [g/dL]

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    HypercalcemiaHypercalcemia

    Polyurea, polydipsiaPolyurea, polydipsia

    Renal colic, lethargyRenal colic, lethargy

    Anorexia, nausea, dyspepsiaAnorexia, nausea, dyspepsia

    Peptic ulcer, depression, drowsinessPeptic ulcer, depression, drowsiness

    Impaired cognitionImpaired cognition

    Acute/chronic onsetAcute/chronic onset

    Malignant Hypercalcaemia Ca>12 mg/dlMalignant Hypercalcaemia Ca>12 mg/dl

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    Causes of HypercalcemiaCauses of Hypercalcemia

    Abnormal parathyroid gland functionAbnormal parathyroid gland function

    Primary or tertiary hyperparathyroidismPrimary or tertiary hyperparathyroidism

    Lithium inducedLithium induced

    familial hypocalciuric hypercalcaemiafamilial hypocalciuric hypercalcaemia

    MalignancyMalignancy

    Lungs, brea

    st, renal, ovar

    ian, colon,Lung

    s, brea

    st, renal, ovar

    ian, colon,Thyroid malignancy.Thyroid malignancy.

    haematologic malignancy (multiplehaematologic malignancy (multiplemyeloma, Lymphoproliferative disorders)myeloma, Lymphoproliferative disorders)

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    ContdContdV

    itaminV

    itamin--D

    metab

    olic disordersD

    metab

    olic disorders hypervitaminosis D (vitamin Dhypervitaminosis D (vitamin D

    intoxication)intoxication) elevated 1,25(OH)2D levels (e.g.elevated 1,25(OH)2D levels (e.g.

    sarcoidosis)sarcoidosis)

    OthersOthers ThyrotoxicosisThyrotoxicosis TSH, FT3, FT4TSH, FT3, FT4 Thiazide useThiazide use Paget's disease of the bonePaget's disease of the bone Addisons diseaseAddisons disease severe secondary hyperparathyroidismsevere secondary hyperparathyroidism milkmilk--alkalisyndromealkalisyndrome

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    TreatmentTreatment

    Hydrate with Normal saline: 4Hydrate with Normal saline: 4--6L deficient6L deficient

    Diuretics: Look for K, MgDiuretics: Look for K, Mg

    Salmon calcitonin: BD, 5Salmon calcitonin: BD, 5--8 u/Kg, 38 u/Kg, 3--4 days4 days

    BISPHOSPHONATES: Pamidronate &BISPHOSPHONATES: Pamidronate &Zoledronic acidZoledronic acid

    Plicamycine / Gallium nitrate (toxic)Plicamycine / Gallium nitrate (toxic)

    Steroids: 40mg/day In granulomatousSteroids: 40mg/day In granulomatoussarcoidosissarcoidosis

    HaemodialysisHaemodialysis

    Treat causeTreat cau

    se

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    HypercalcaemiaHypercalcaemia Oral, perioral and acral paresthesias, tingling orOral, perioral and acral paresthesias, tingling or

    'pins and needles' sensation. Thisis often the'pins and needles' sensation. Thisis often theearliest symptom of hypocalcaemia.earliest symptom of hypocalcaemia.

    Carpopedal Spasm and generalized tetanyCarpopedal Spasm and generalized tetany Latent tetany: Trousseau sign of latent tetanyLatent tetany: Trousseau sign of latent tetany

    (eliciting carpal spasm by inflating the blood(eliciting carpal spasm by inflating the blood

    pressure cuff and maintaining the cuff pressurepressure cuff and maintaining the cuff pressureabove systolic).above systolic).Chvostek'ssign (tapping of the inferior portion ofChvostek'ssign (tapping of the inferior portion ofthe zygoma will produce facial spasms).the zygoma will produce facial spasms).

    Epilepsy, PsycosisEpilepsy, Psycosis

    PapilloedemaPapilloedema Basal ganglia CalcificationBasal ganglia Calcification Metastatic calcificationMetastatic calcification

    Severe Hypocalcaemia

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    Causes of HypocalcaemiaCauses of Hypocalcaemia

    Absent parathyroid hormone (PTH)Absent parathyroid hormone (PTH) Hereditary hypoparathyroidismHereditary hypoparathyroidism

    Following parathyroidectomyFollowing parathyroidectomy

    Following thyroidectomy, the parathyroid glandsFollowing thyroidectomy, the parathyroid glandsare located very close to the thyroid and areare located very close to the thyroid and areeasily injured or even accidentally removedeasily injured or even accidentally removedduring thyroidectomyduring thyroidectomy

    In DiGeorge Syndrome, a disease characterizedIn DiGeorge Syndrome, a disease characterized

    by the failure of the th

    ird and fourth pharyngealby the fa

    ilure of the th

    ird and fourth pharyngealpouches to develop, the parathyroid glands dopouches to develop, the parathyroid glands do

    not form and there is thus a lack ofPTH.not form and there is thus a lack ofPTH.

    StorageStorage Al, Cu, FeAl, Cu, Fe

    Trauma or vascular formationTrauma or vascular formation

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    Contd.Contd.

    Alkalosis: Resp. + MetabolicAlkalosis: Resp. + Metabolic CRFCRF

    Vit. D deficiency, Malabsoption syndromeVit. D deficiency, Malabsoption syndrome

    Pseudo hypoparathyro

    idis

    mPs

    eudo hypoparathyroidis

    m Acute pancreatitisAcute pancreatitis

    DrugDrug-- Ca lowering drugsCa lowering drugs

    Massive Blood transfusionMassive Blood transfusion

    Osteoblastic metastasisOsteoblastic metastasis

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    Treatment of HypocalcaemiaTreatment of Hypocalcaemia

    If alkalosis: Rebreath expired air or 5%If alkalosis: Rebreath expired air or 5%COCO22 in Oin O22 ..

    10% Calcium gluconate slow IV to keep10% Calcium gluconate slow IV to keep

    Ca >7mg/dl till relief.Ca >7mg/dl till relief. Oral Calcium: 1.5Oral Calcium: 1.5--3 gms elemental Ca,3 gms elemental Ca,

    500 mg of Ca tab.500 mg of Ca tab.

    Ifserum Ca fall bellow 7mg/dl, give againIfserum Ca fall bellow 7mg/dl, give again

    after 6hrs Ca gluconate Upto 100mg/day.after 6hrs Ca gluconate Upto 100mg/day. Tab. 1Tab. 1 in persistant hypo parathyroidismin persistant hypo parathyroidism

    Magnesium (nalepsin) in calcium resistantMagnesium (nalepsin) in calcium resistantpersonspersons

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    HyperparathyroidismHyperparathyroidism

    Primary:Primary:Single adenomaSingle adenoma--90%90%

    Multiple adenomaMultiple adenoma--4%4%

    Nodular hyperplasiaNodular hyperplasia--5%5%

    CarcinomaCarcinoma--1%1%

    S. CaS. Ca PTHPTH

    Secondary:Secondary:

    CRF (specially)CRF (specially)

    MalabsorptionMalabsorption

    Osteomalacia & ricketOsteomalacia & ricket

    S.CaS.Ca PTHPTH

    Tertiary:Tertiary:

    Esp. CRFEsp. CRF

    S. CaS. Ca PTHPTH

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    Contd.Contd.

    Serum bi

    ochemi

    cal hyper and hypoSerum bi

    ochemi

    cal hyper and hypocalcaemia occupies the clinicalcalcaemia occupies the clinicalspectrum of parathyroid disease. Sospectrum of parathyroid disease. Soare the features of hyper/hypoare the features of hyper/hypo

    calcaemia.calcaemia.

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    DiagnosisDiagnosis

    Features

    of hypercalcaemiaFeature

    sof hypercalcaem

    ia

    PTH radioPTH radio--immuno assayimmuno assay

    24 hr urinary calcium increased24 hr urinary calcium increased

    Radiology: Osteitis fibrosa cystica,Radiology: Osteitis fibrosa cystica,

    Pepperpot skull,Pepperpot skull,

    Bone cystBone cyst-- brown tumourbrown tumour

    Tumour localisation byTumour localisation by-- Surgery, USG, CT,Surgery, USG, CT,Neck catheterisation, PTH measurement,Neck catheterisation, PTH measurement,Technetium isotope imaging.Technetium isotope imaging.

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    TreatmentTreatment

    Manage hypercalcaemiaManage hypercalcaemia Remove the tumourRemove the tumour

    Tagging the remnantTagging the remnant

    Transplant in symptomatic, young &Transplant in symptomatic, young &progressiveprogressive

    Secondary: Calcitriol to suppressPTHSecondary: Calcitriol to suppressPTHTertiary: RemoveTertiary: Remove

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    HypoparathyroidismHypoparathyroidism

    Hypocalcaemia, signs and symptomsHypocalcaemia, signs and symptomsof decreased Ca.of decreased Ca.

    HyperphosphatemiaHyperphosphatemia Undetectable PTHUndetectable PTH

    Exclude serum Mg deficiency. If (+)Exclude serum Mg deficiency. If (+)

    Functional Hypoparathyro

    idis

    m.Functional Hypoparathyro

    idis

    m.

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    HypoparathyroidismHypoparathyroidism

    It is due to destruction,It is due to destruction,

    surgery,surgery,

    Vascular damage, orVascular damage, or idiopathic as part of polyidiopathic as part of poly--glandularglandular

    failure or agenesis (DiGeorgefailure or agenesis (DiGeorgesyndrome)

    syndrome)

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    PseudohypoparathyroidismPseudohypoparathyroidism

    PseudohypoparathyroidismPseudohypoparathyroidismis

    ais

    acondition associated primarily withcondition associated primarily withresistance to the parathyroid hormone.resistance to the parathyroid hormone.Patients have a low serum calcium andPatients have a low serum calcium andhigh phosphate, but the parathyroidhigh phosphate, but the parathyroid

    hormone level (PTH)

    isactuallyhormone level (

    PTH)

    isactuallyappropriately high (due to theappropriately high (due to the

    hypocalcaemia).hypocalcaemia). Increased PTH + biochemically Low CaIncreased PTH + biochemically Low Ca

    and High PO4 + body stigma.and High PO4 + body stigma.

    Features:Features: Short stature, obese withShort stature, obese withround face, short 4round face, short 4thth and 5and 5thth metacarpal,metacarpal,mental retardation, defective teeth & bonemental retardation, defective teeth & boneformationformation

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    ShortShortstature,stature,

    obeseobesewithwithroundround

    faceface

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    blunting of the fourthblunting of the fourth

    and fifth knuckles ofand fifth knuckles ofthe handthe hand

    Short 4Short 4thth and 5and 5thth

    metacarpalsmetacarpals

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    PseudopseudohypoparathyroidismPseudopseudohypoparathyroidism

    PseudopseudohypoparathyroidismPseudopseudohypoparathyroidism((pseudoPHPpseudoPHP) is an inherited disorder,) is an inherited disorder,named for itssimilarity tonamed for itssimilarity topseudohypoparathyroidism inpseudohypoparathyroidism in

    presentation. The termpresentation. The termpseudopseudohypoparathyroidism is usedpseudopseudohypoparathyroidism is usedto describe a condition where theto describe a condition where theindividual has the phenotypic appearanceindividual has the phenotypic appearanceof pseudohypoparathyroidism, but isof pseudohypoparathyroidism, but is

    biochemically normal.biochemically normal.

    It issometimes considered a variant ofIt issometimes considered a variant ofAlbright hereditary osteodystrophy.Albright hereditary osteodystrophy.

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    Young womanYoung woman

    with shortwith shortstature,stature,

    disproportionatedisproportionateshortening ofshortening of

    the limbs,the limbs,

    generalizedgeneralizedobesity, andobesity, and

    round, flattenedround, flattenedface.face.

    Radiograph ofRadiograph of

    the handthe handshowing theshowing theshortened 4thshortened 4th

    and 5thand 5thmetacarpalsmetacarpals

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    Thank YouThank You


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