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Bureaucrats, bureaucrats, nocaptcha, Administrators, Widget editors
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Anmol Pitliya (talk | contribs)
Bureaucrats, bureaucrats, nocaptcha, Administrators, Widget editors
9,217 edits
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|-
|-
! colspan="2" style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Disorder}}
! colspan="2" style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Disorder}}
!Mechanism of hypercalcemia
! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Mechanism of hypercalcemia}}
!Clinical features
! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Clinical features}}
!Laboratory findings
! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Laboratory findings}}
!Imaging & diagnostic modalities
! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Imaging & diagnostic modalities}}
|-
|-
| rowspan="3" |Hyperparathyroidism
| rowspan="3"  style="background: #F0FFFF; text-align: center;" |'''Hyperparathyroidism'''
|Primary hyperparathyroidism
| style="background: #F0FFFF; text-align: center;" |Primary hyperparathyroidism
|Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a primary process in [[parathyroid gland]]. Parathyroid hormone causes increase in serum calcium.
| style="background: #DCDCDC;" |Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a primary process in [[parathyroid gland]]. Parathyroid hormone causes increase in serum calcium.
|
| style="background: #DCDCDC;" |
* Usually asymptomatic
* Usually asymptomatic
* Hypercalcemia detected on routine biochemical  panel
* Hypercalcemia detected on routine biochemical  panel
|
| style="background: #DCDCDC;" |
* ↑ PTH
* ↑ PTH
* ↑ Calcium
* ↑ Calcium
* ''↓/N Phosphate''
* ''↓/N Phosphate''
* N/↑ calcitriol
* N/↑ calcitriol
| rowspan="3" |Findings of bone resorption:
| rowspan="3" style="background: #DCDCDC;" |Findings of bone resorption:
* X-ray
* X-ray
* DXA
* DXA
Line 76: Line 76:
* Intraoperative parathyroid hormone monitoring
* Intraoperative parathyroid hormone monitoring
|-
|-
|Secondary hyperparathyroidism
| style="background: #F0FFFF; text-align: center;" |Secondary hyperparathyroidism
|Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a secondary process. Parathyroid hormone causes increase in serum calcium.
| style="background: #DCDCDC;" |Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a secondary process. Parathyroid hormone causes increase in serum calcium.
|
| style="background: #DCDCDC;" |
* May present with history of:
* May present with history of:
** Chronic renal failure
** Chronic renal failure
** Vitamin D deficiency
** Vitamin D deficiency
|
| style="background: #DCDCDC;" |
* '''↑''' PTH
* '''↑''' PTH
* '''''↓/'''N'' Calcium
* '''''↓/'''N'' Calcium
* ''↑ Phosphate''
* ''↑ Phosphate''
|-
|-
|Tertiary hyperparathyroidism
| style="background: #F0FFFF; text-align: center;" |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.
| style="background: #DCDCDC;" |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.
|
| style="background: #DCDCDC;" |
* Usually present with history of:
* Usually present with history of:
** Kidney transplant
** Kidney transplant
* Usually hyperplasia of all four parathyroid glands
* Usually hyperplasia of all four parathyroid glands
|
| style="background: #DCDCDC;" |
* '''↑''' PTH
* '''↑''' PTH
* '''''↑''''' Calcium
* '''''↑''''' Calcium
* ''↑ Phosphate''
* ''↑ Phosphate''
|-
|-
| rowspan="4" |Malignancy
| rowspan="4"  style="background: #F0FFFF; text-align: center;" |'''Malignancy'''
|Humoral hypercalcemia of malignancy
| style="background: #F0FFFF; text-align: center;" |Humoral hypercalcemia of malignancy
|Tumor cells secretes parathyroid hormone related protein (PTHrP) which has similar action as parathyroid hormone.
| style="background: #DCDCDC;" |Tumor cells secretes parathyroid hormone related protein (PTHrP) which has similar action as parathyroid hormone.
|
| style="background: #DCDCDC;" |
* Most common cause of malignancy related hypercalcemia.
* Most common cause of malignancy related hypercalcemia.
* Usually present in solid tumors
* Usually present in solid tumors
|
| style="background: #DCDCDC;" |
* '''↑''' PTHrP
* '''↑''' PTHrP
* '''''↑''''' Calcium
* '''''↑''''' Calcium
* '''↓'''/N P''hosphate''
* '''↓'''/N P''hosphate''
* N/↑ Calcitriol
* N/↑ Calcitriol
|
| style="background: #DCDCDC;" |
* Chest X-ray
* Chest X-ray
* CT scan
* CT scan
* MRI
* MRI
|-
|-
|Osteolytic tumors
| style="background: #F0FFFF; text-align: center;" |Osteolytic tumors
|Multiple myeloma produces osteolysis of bones causing hypercalcemia. Osteolytic metastasis can cause bone resorption causing hypercalcemia.
| style="background: #DCDCDC;" |Multiple myeloma produces osteolysis of bones causing hypercalcemia. Osteolytic metastasis can cause bone resorption causing hypercalcemia.
|
| style="background: #DCDCDC;" |
* Most commonly present in multiple myeloma and breast cancer.
* Most commonly present in multiple myeloma and breast cancer.
|
| style="background: #DCDCDC;" |
* '''''↓''''' PTH
* '''''↓''''' PTH
* '''↑''' Calcium
* '''↑''' Calcium
|
| style="background: #DCDCDC;" |
* DXA
* DXA
* X-ray
* X-ray
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* Serum protein electrophoresis
* Serum protein electrophoresis
|-
|-
|Production of calcitirol
| style="background: #F0FFFF; text-align: center;" |Production of calcitirol
|Some tumors has ectopic activity of 1-alpha-hydroxylase leading to increased production of calcitriol. Calcitriol is active form of vitamin D and causes hypercalcemia.  
| style="background: #DCDCDC;" |Some tumors has ectopic activity of 1-alpha-hydroxylase leading to increased production of calcitriol. Calcitriol is active form of vitamin D and causes hypercalcemia.  
|
| style="background: #DCDCDC;" |
* Most commonly present in lymphomas and in some ovarian germ cell tumors.
* Most commonly present in lymphomas and in some ovarian germ cell tumors.
|
| style="background: #DCDCDC;" |
* '''↑''' Calcium
* '''↑''' Calcium
* ↑ Calcitriol
* ↑ Calcitriol
|
| style="background: #DCDCDC;" |
* CT scan
* CT scan
* MRI
* MRI
|-
|-
|Ectopic parathyroid hormone
| style="background: #F0FFFF; text-align: center;" |Ectopic parathyroid hormone
|Some tumors leads to ectopic production of parathyroid hormone.
| style="background: #DCDCDC;" |Some tumors leads to ectopic production of parathyroid hormone.
|
| style="background: #DCDCDC;" |
* In rare instances, small cell carcinoma of lung may produce hypercalcemia by this process.
* In rare instances, small cell carcinoma of lung may produce hypercalcemia by this process.
|
| style="background: #DCDCDC;" |
* ↑ PTH
* ↑ PTH
* ↑ Calcium
* ↑ Calcium
* ''↓/N Phosphate''
* ''↓/N Phosphate''
* N/↑ Calcitriol
* N/↑ Calcitriol
|
| style="background: #DCDCDC;" |
* Chest X-ray
* Chest X-ray
* CT scan
* CT scan
* MRI
* MRI
|-
|-
| rowspan="2" |Medication induced
| rowspan="2"  style="background: #F0FFFF; text-align: center;" |'''Medication induced'''
|Lithium
| style="background: #F0FFFF; text-align: center;" |Lithium
|Lithium lowers urinary calcium and causes hypercalcemia. Lithium has been reported to cause an increase in parathyroid hormones and enlargement if parathyroid gland after weeks to months of therapy.
| style="background: #DCDCDC;" |Lithium lowers urinary calcium and causes hypercalcemia. Lithium has been reported to cause an increase in parathyroid hormones and enlargement if parathyroid gland after weeks to months of therapy.
|
| style="background: #DCDCDC;" |
* History of mood disorder
* History of mood disorder
|
| style="background: #DCDCDC;" |
* ↑ PTH
* ↑ PTH
* ↑ Calcium
* ↑ Calcium
|
| style="background: #DCDCDC;" |
* Lithium levels
* Lithium levels
|-
|-
|Thiazide diuretics
| style="background: #F0FFFF; text-align: center;" |Thiazide diuretics
|Thiazide diuretics lowers urinary calcium excretion and causes hypercalcemia
| style="background: #DCDCDC;" |Thiazide diuretics lowers urinary calcium excretion and causes hypercalcemia
|
| style="background: #DCDCDC;" |
* History of cardiac disorder
* History of cardiac disorder
* Rarely causes hypercalcemia
* Rarely causes hypercalcemia
|
| style="background: #DCDCDC;" |
* ↑ Calcium
* ↑ Calcium
| --
|  style="background: #DCDCDC;" |--
|-
|-
| rowspan="2" |Nutritional
| rowspan="2"  style="background: #F0FFFF; text-align: center;" |'''Nutritional'''
|Milk-alkali syndrome
| style="background: #F0FFFF; text-align: center;" |Milk-alkali syndrome
|Hypercalcemia is be caused by high intake of calcium carbonate
| style="background: #DCDCDC;" |Hypercalcemia is be caused by high intake of calcium carbonate
|
| style="background: #DCDCDC;" |
* History of
* History of
** High milk intake
** High milk intake
Line 185: Line 184:
*** Dyspepsia
*** Dyspepsia
* May lead to metabolic alkalosis and renal insufficiency.
* May lead to metabolic alkalosis and renal insufficiency.
|
| style="background: #DCDCDC;" |
* ↑ Calcium
* ↑ Calcium
|
| style="background: #DCDCDC;" |
* Renal function test
* Renal function test
|-
|-
|Vitamin D toxicity
| style="background: #F0FFFF; text-align: center;" |Vitamin D toxicity
|Excess vitamin D causes increased absorption of calcium from intestine causing hypercalcemia.
| style="background: #DCDCDC;" |Excess vitamin D causes increased absorption of calcium from intestine causing hypercalcemia.
|
| style="background: #DCDCDC;" |
* History of:
* History of:
** Excess intake vitamin D
** Excess intake vitamin D
** Excess milk fortified with vitamin D
** Excess milk fortified with vitamin D
** Topical application of vitamin D analogue analogue calcipotriol
** Topical application of vitamin D analogue analogue calcipotriol
|
| style="background: #DCDCDC;" |
* '''↑''' Calcium
* '''↑''' Calcium
* ↑ Vitamin D (calcidiol and/or calcitriol)
* ↑ Vitamin D (calcidiol and/or calcitriol)
| --
| style="background: #DCDCDC;" | --
|-
|-
|Granulomatous disease
| style="background: #F0FFFF; text-align: center;" |'''Granulomatous disease'''
|Sarcoidosis
| style="background: #F0FFFF; text-align: center;" |Sarcoidosis
|Hypercalcemia is causes by endogeous production of calcitriol by disease-activated macrophages.
| style="background: #DCDCDC;" |Hypercalcemia is causes by endogeous production of calcitriol by disease-activated macrophages.
|
| style="background: #DCDCDC;" |
* History of:
* History of:
** Cough
** Cough
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** Fever
** Fever
** Weight loss
** Weight loss
|
| style="background: #DCDCDC;" |
* '''↑''' Calcium
* '''↑''' Calcium
* ↑ Calcitriol
* ↑ Calcitriol
* ↑ ACE levels
* ↑ ACE levels
|
| style="background: #DCDCDC;" |
* Chest X-ray
* Chest X-ray
* Biopsy
* Biopsy
|}
|}

Revision as of 14:09, 8 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 of 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
  • N/↑ calcitriol
 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 Humoral hypercalcemia of malignancy Tumor cells secretes parathyroid hormone related protein (PTHrP) which has similar action as parathyroid hormone.
  • Most common cause of malignancy related hypercalcemia.
  • Usually present in solid tumors
  • ↑ PTHrP
  • ↑ Calcium
  • ↓/N Phosphate
  • N/↑ Calcitriol
  • Chest X-ray
  • CT scan
  • MRI
Osteolytic tumors Multiple myeloma produces osteolysis of bones causing hypercalcemia. Osteolytic metastasis can cause bone resorption causing hypercalcemia.
  • Most commonly present in multiple myeloma and breast cancer.
  • ↓ PTH
  • ↑ Calcium
  • DXA
  • X-ray
  • Mammography
  • Ultrasound
  • ESR
  • Serum protein electrophoresis
Production of calcitirol Some tumors has ectopic activity of 1-alpha-hydroxylase leading to increased production of calcitriol. Calcitriol is active form of vitamin D and causes hypercalcemia.
  • Most commonly present in lymphomas and in some ovarian germ cell tumors.
  • ↑ Calcium
  • ↑ Calcitriol
  • CT scan
  • MRI
Ectopic parathyroid hormone Some tumors leads to ectopic production of parathyroid hormone.
  • In rare instances, small cell carcinoma of lung may produce hypercalcemia by this process.
  • ↑ PTH
  • ↑ Calcium
  • ↓/N Phosphate
  • N/↑ Calcitriol
  • Chest X-ray
  • CT scan
  • MRI
Medication induced Lithium Lithium lowers urinary calcium and causes hypercalcemia. Lithium has been reported to cause an increase in parathyroid hormones and enlargement if parathyroid gland after weeks to months of therapy.
  • History of mood disorder
  • ↑ PTH
  • ↑ Calcium
  • Lithium levels
Thiazide diuretics Thiazide diuretics lowers urinary calcium excretion and causes hypercalcemia
  • History of cardiac disorder
  • Rarely causes hypercalcemia
  • ↑ Calcium
 --
Nutritional Milk-alkali syndrome Hypercalcemia is be caused by high intake of calcium carbonate
  • History of
    • High milk intake
    • Excess calcium intake for treating:
      • Osteoporosis
      • Dyspepsia
  • May lead to metabolic alkalosis and renal insufficiency.
  • ↑ Calcium
  • Renal function test
Vitamin D toxicity Excess vitamin D causes increased absorption of calcium from intestine causing hypercalcemia.
  • History of:
    • Excess intake vitamin D
    • Excess milk fortified with vitamin D
    • Topical application of vitamin D analogue analogue calcipotriol
  • ↑ Calcium
  • ↑ Vitamin D (calcidiol and/or calcitriol)
 --
Granulomatous disease Sarcoidosis Hypercalcemia is causes by endogeous production of calcitriol by disease-activated macrophages.
  • History of:
    • Cough
    • Dyspnea
    • Chest pain
    • Tiredness or weakness
    • Fever
    • Weight loss
  • ↑ Calcium
  • ↑ Calcitriol
  • ↑ ACE levels
  • Chest X-ray
  • Biopsy
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