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== Differential diagnosis ==
== Differential diagnosis ==
{| class="wikitable"
{| class="wikitable"
! colspan="5" |Differential diagnosis fo hyperparathyroidism on the basis of hypercalcemia
! colspan="6" |Differential diagnosis fo hyperparathyroidism on the basis of hypercalcemia
|-
|-
! colspan="2" |Disorder
! colspan="2" |Disorder
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!Clinical features
!Clinical features
!Laboratory findings
!Laboratory findings
!Imaging & diagnostic modalities
|-
|-
| rowspan="3" |Hyperparathyroidism
| rowspan="3" |Hyperparathyroidism
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|
|
* ↑ PTH
* ↑ PTH
* ↑ Ca
* ↑ Calcium
* ''↓/N phosphate''
* ''↓/N phosphate''
| rowspan="3" |Findings of bone resorption:
* X-ray
* DXA
Preoperative localization of hyperfunctioning parathyroid gland:
* Non-Invasive
** Tc-99m sestamibi scintigraphy
** Neck ultrasound
** 4D-CT
** SPET(P-SPECT)
** PET
** MRI
* Invasive:
** Super sensitive venous sampling
** Selective arteriography
** Angiography
Predicting post-operative success:
* Intraoperative parathyroid hormone monitoring
|-
|-
|Secondary hyperparathyroidism
|Secondary hyperparathyroidism
|Increase in [[secretion]] of [[parathyroid hormone]] from a secondary process. Parathyroid hormone causes increase in serum calcium.
|Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a secondary process. Parathyroid hormone causes increase in serum calcium.
|
|
* May present with history of:
* May present with history of:
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|
|
* '''↑''' PTH
* '''↑''' PTH
* '''''↓/'''N'' Ca
* '''''↓/'''N'' Calcium
* ''↑ phosphate''
* ''↑ phosphate''
|-
|-
|Tertiary hyperparathyroidism
|Tertiary hyperparathyroidism
|continuous elevation of [[parathyroid hormone]] even after successful treatment of the secondary cause of  elevated parathyroid hormone. Parathyroid hormone causes increase in serum calcium.
|Continuous elevation of [[parathyroid hormone]] (PTH) even after successful treatment of the secondary cause of  elevated parathyroid hormone. Parathyroid hormone causes increase in serum calcium.
|
|
* Usually present with history of:
* Usually present with history of:
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* Usually hyperplasia of all four parathyroid glands
* Usually hyperplasia of all four parathyroid glands
|
|
* '''↑''' PTH
* '''''↑''''' Calcium
* ''↑ phosphate''
|-
|-
| rowspan="2" |Malignancy
| rowspan="2" |Malignancy
|Para-neplastic syndroms
|Para-neoplastic syndrome
|
|
|
|
|
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|-
|-
|Hypercalcemia due to bone destruction
|Hypercalcemia due to bone destruction
|
|
|
|
|
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| rowspan="2" |Medication induced
| rowspan="2" |Medication induced
|Lithium
|Lithium
|
|
|
|
|
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|-
|-
|Thiazide diuretics
|Thiazide diuretics
|
|
|
|
|
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| rowspan="2" |Nutritional
| rowspan="2" |Nutritional
|Milk-alkali syndrome
|Milk-alkali syndrome
|
|
|
|
|
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|-
|-
|Vitamin D toxicity
|Vitamin D toxicity
|
|
|
|
|
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|Granulomatous disease
|Granulomatous disease
|Sarcoidosis
|Sarcoidosis
|
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|
|
|
|
|
|}
|}

Revision as of 18:15, 7 September 2017

There are three types of hyperparathyroidism and should be differentiated between each other. Hyperparathyroidism should be differeniated from other causes of hypercalcemia. Causes of hypercalcemia include:

  • Parathyroid related
    • Primary hyperparathyroidism
      • Typical primary hyperparathyroidism
      • Familial hypocalciuric hypercalcemia
    • Secondary hyperparathyroidism
    • Tertiary hyperparathyroidism
  • Non-parathyroid related
    • Malignancy
      • Para-neoplastic syndrome: Parathyroid hormone related peptide
      • Hypercalcemia due to bone destruction
    • Medication induced
      • Thiazide diuretics
      • Lithium
    • Nutritional
      • Milk alkali syndrome
      • Vitamin D toxicity
    • Granulomatous disease
      • Sarcoidosis
    • Surgical
      • Immobilization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypercalcemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Related to Parathyroid gland
 
 
 
 
 
 
 
 
 
 
 
Unrelated to parathyroid gland
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hyperparathyroidism
 
 
Secondary hyperparathyroidism
 
 
Tertiary hyperparathyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Typical primary hyperparathyroidism
 
Familial hypocalciuric hypercalcemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignancy
 
 
 
 
 
Medication induced
 
 
 
Nutritional
 
 
 
 
Granulomatous disease
 
 
Surgical
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Para-neoplastic syndrome: Parathyroid hormone related peptide
 
Metaplasia: Hypercalcemia due to bone destruction
 
Thiazide diuretics
 
Lithium
 
Milk alkali syndrome
 
Vitamin D toxicity
 
Sarcoidosis
 
 
Immobilization
 

Differential diagnosis

Differential diagnosis fo hyperparathyroidism on the basis of hypercalcemia
Disorder Mechanism of hypercalcemia Clinical features Laboratory findings Imaging & diagnostic modalities
Hyperparathyroidism Primary hyperparathyroidism Increase in secretion of parathyroid hormone (PTH) from a primary process in parathyroid gland. Parathyroid hormone causes increase in serum calcium.
  • Usually asymptomatic
  • Hypercalcemia detected on routine biochemical panel
  • ↑ PTH
  • ↑ Calcium
  • ↓/N phosphate
 Findings of bone resorption:
  • X-ray
  • DXA

Preoperative localization of hyperfunctioning parathyroid gland:

  • Non-Invasive
    • Tc-99m sestamibi scintigraphy
    • Neck ultrasound
    • 4D-CT
    • SPET(P-SPECT)
    • PET
    • MRI
  • Invasive:
    • Super sensitive venous sampling
    • Selective arteriography
    • Angiography

Predicting post-operative success:

  • Intraoperative parathyroid hormone monitoring
Secondary hyperparathyroidism Increase in secretion of parathyroid hormone (PTH) from a secondary process. Parathyroid hormone causes increase in serum calcium.
  • May present with history of:
    • Chronic renal failure
    • Vitamin D deficiency
  • ↑ PTH
  • ↓/N Calcium
  • ↑ phosphate
Tertiary hyperparathyroidism Continuous elevation of parathyroid hormone (PTH) even after successful treatment of the secondary cause of elevated parathyroid hormone. Parathyroid hormone causes increase in serum calcium.
  • Usually present with history of:
    • Kidney transplant
  • Usually hyperplasia of all four parathyroid glands
  • ↑ PTH
  • ↑ Calcium
  • ↑ phosphate
Malignancy Para-neoplastic syndrome
Hypercalcemia due to bone destruction
Medication induced Lithium
Thiazide diuretics
Nutritional Milk-alkali syndrome
Vitamin D toxicity
Granulomatous disease Sarcoidosis
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