CALCIUM HOMEOSTASIS & PARATHYROID DISORDERS

DR. MAHMUDUL HUQUE HOLY FAMILY RED CRESCENT MEDICAL COLLEGE

Calcium Homeostasis


calcium homeostasis is the mechanism by which the body maintains adequate calcium levels. Derangements of this mechanism lead to hypercalcaemia or hypocalcaemia, both of which can have important consequences for health.

Normal range: 910.5 mg/dL or 2.2 2.22.6 mmol/L

Corrected Ca level


Corrected calcium (mg/dL) = measured total Ca (mg/dL) + 0.8 X (4.0 - serum albumin [g/dL]

Hypercalcemia
    

Polyurea, polydipsia Renal colic, lethargy Anorexia, nausea, dyspepsia Peptic ulcer, depression, drowsiness Impaired cognition Acute/chronic onset Malignant Hypercalcaemia Ca>12 mg/dl

 

Causes of Hypercalcemia
Abnormal parathyroid gland function  Primary or tertiary hyperparathyroidism  Lithium induced  familial hypocalciuric hypercalcaemia Malignancy  Lungs, breast, renal, ovarian, colon, Thyroid malignancy.  haematologic malignancy (multiple myeloma, Lymphoproliferative disorders)

Contd
Vitamin-D metabolic disorders Vitamin hypervitaminosis D (vitamin D intoxication)  elevated 1,25(OH)2D levels (e.g. sarcoidosis) Others  Thyrotoxicosis TSH, FT3, FT4  Thiazide use  Paget's disease of the bone  Addisons disease  severe secondary hyperparathyroidism  milk-alkali syndrome milk-

Treatment
   

 

 

Hydrate with Normal saline: 4-6L deficient 4Diuretics: Look for K, Mg Salmon calcitonin: BD, 5-8 u/Kg, 3-4 days 53BISPHOSPHONATES: Pamidronate & Zoledronic acid Plicamycine / Gallium nitrate (toxic) Steroids: 40mg/day In granulomatous sarcoidosis Haemodialysis Treat cause

Hypercalcaemia
  

   

Oral, perioral and acral paresthesias, tingling or 'pins and needles' sensation. This is often the earliest symptom of hypocalcaemia. Carpopedal Spasm and generalized tetany Latent tetany: Trousseau sign of latent tetany (eliciting carpal spasm by inflating the blood pressure cuff and maintaining the cuff pressure above systolic). Chvostek's sign (tapping of the inferior portion of the zygoma will produce facial spasms). Epilepsy, Psycosis Papilloedema Basal ganglia Calcification Metastatic calcification Severe Hypocalcaemia <6mg/dl

Causes of Hypocalcaemia
Absent parathyroid hormone (PTH)
  

 

Hereditary hypoparathyroidism Following parathyroidectomy Following thyroidectomy, the parathyroid glands are located very close to the thyroid and are easily injured or even accidentally removed during thyroidectomy In DiGeorge Syndrome, a disease characterized by the failure of the third and fourth pharyngeal pouches to develop, the parathyroid glands do not form and there is thus a lack of PTH. Storage Al, Cu, Fe Trauma or vascular formation

Contd.
       

Alkalosis: Resp. + Metabolic CRF Vit. D deficiency, Malabsoption syndrome Pseudo hypoparathyroidism Acute pancreatitis DrugDrug- Ca lowering drugs Massive Blood transfusion Osteoblastic metastasis

Treatment of Hypocalcaemia
If alkalosis: Rebreath expired air or 5% CO2 in O2 . 10% Calcium gluconate slow IV to keep Ca >7mg/dl till relief. Oral Calcium: 1.5-3 gms elemental Ca, 1.5500 mg of Ca tab. If serum Ca fall bellow 7mg/dl, give again after 6hrs Ca gluconate Upto 100mg/day. Tab. 1 in persistant hypo parathyroidism Magnesium (nalepsin) in calcium resistant persons

Hyperparathyroidism
Primary: Single adenoma-90% adenomaMultiple adenoma-4% adenomaNodular hyperplasia-5% hyperplasiaCarcinoma-1% CarcinomaSecondary: CRF (specially) Malabsorption Osteomalacia & ricket Tertiary: Esp. CRF S. Ca PTH

S.Ca

PTH

S. Ca

PTH

Contd.


Serum biochemical hyper and hypo calcaemia occupies the clinical spectrum of parathyroid disease. So are the features of hyper/hypo calcaemia.

Diagnosis
   

Features of hypercalcaemia PTH radio-immuno assay radio24 hr urinary calcium increased Radiology: Osteitis fibrosa cystica, Pepperpot skull, Bone cyst- brown tumour cystTumour localisation by- Surgery, USG, CT, byNeck catheterisation, PTH measurement, Technetium isotope imaging.

Treatment
   

Manage hypercalcaemia Remove the tumour Tagging the remnant Transplant in symptomatic, young & progressive

Secondary: Calcitriol to suppress PTH Tertiary: Remove

Hypoparathyroidism


  

Hypocalcaemia, signs and symptoms of decreased Ca. Hyperphosphatemia Undetectable PTH Exclude serum Mg deficiency. If (+) Functional Hypoparathyroidism.

Hypoparathyroidism
   

It is due to destruction, surgery, Vascular damage, or idiopathic as part of poly-glandular polyfailure or agenesis (DiGeorge syndrome)

Pseudohypoparathyroidism


Pseudohypoparathyroidism is a condition associated primarily with resistance to the parathyroid hormone. Patients have a low serum calcium and high phosphate, but the parathyroid hormone level (PTH) is actually appropriately high (due to the hypocalcaemia). Increased PTH + biochemically Low Ca and High PO4 + body stigma. Features: Short stature, obese with round face, short 4th and 5th metacarpal, mental retardation, defective teeth & bone formation

Short stature, obese with round face

blunting of the fourth and fifth knuckles of the hand

Short 4th and 5th metacarpals

Pseudopseudohypoparathyroidism


Pseudopseudohypoparathyroidism (pseudoPHP) is an inherited disorder, pseudoPHP) named for its similarity to pseudohypoparathyroidism in presentation. The term pseudopseudohypoparathyroidism is used to describe a condition where the individual has the phenotypic appearance of pseudohypoparathyroidism, but is biochemically normal. It is sometimes considered a variant of Albright hereditary osteodystrophy.

Young woman with short stature, disproportionate shortening of the limbs, generalized obesity, and round, flattened face. Radiograph of the hand showing the shortened 4th and 5th metacarpals

Thank You