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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