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| == Differential diagnosis == | | == Differential diagnosis == |
| {|
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| ! colspan="6" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF||Differential diagnosis of hyperparathyroidism on the basis of hypercalcemia}}
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| |-
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| ! colspan="2" style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Disorder}}
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| ! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Mechanism of hypercalcemia}}
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| ! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Clinical features}}
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| ! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Laboratory findings}}
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| ! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Imaging & diagnostic modalities}}
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| |-
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| | rowspan="3" style="background: #F0FFFF; text-align: center;" |'''Hyperparathyroidism'''
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| | style="background: #F0FFFF; text-align: center;" |Primary hyperparathyroidism
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| | style="background: #DCDCDC;" |Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a primary process in [[parathyroid gland]]. Parathyroid hormone causes increase in serum calcium.
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| | style="background: #DCDCDC;" |
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| * Usually asymptomatic
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| * Hypercalcemia detected on routine biochemical panel
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| | style="background: #DCDCDC;" |
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| * ↑ PTH
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| * ↑ Calcium
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| * ''↓/N Phosphate''
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| * N/↑ calcitriol
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| | rowspan="3" style="background: #DCDCDC;" |Findings of bone resorption:
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| * X-ray
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| * DXA
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| Preoperative localization of hyperfunctioning parathyroid gland:
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| * Non-Invasive
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| ** Tc-99m sestamibi scintigraphy
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| ** Neck ultrasound
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| ** 4D-CT
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| ** SPET(P-SPECT)
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| ** PET
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| ** MRI
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| * Invasive:
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| ** Super sensitive venous sampling
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| ** Selective arteriography
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| ** Angiography
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| Predicting post-operative success:
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| * Intraoperative parathyroid hormone monitoring
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Secondary hyperparathyroidism
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| | style="background: #DCDCDC;" |Increase in [[secretion]] of [[parathyroid hormone]] (PTH) from a secondary process. Parathyroid hormone causes increase in serum calcium.
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| | style="background: #DCDCDC;" |
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| * May present with history of:
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| ** Chronic renal failure
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| ** Vitamin D deficiency
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| | style="background: #DCDCDC;" |
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| * '''↑''' PTH
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| * '''''↓/'''N'' Calcium
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| * ''↑ Phosphate''
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Tertiary hyperparathyroidism
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| | 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.
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| | style="background: #DCDCDC;" |
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| * Usually present with history of:
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| ** Kidney transplant
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| * Usually hyperplasia of all four parathyroid glands
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| | style="background: #DCDCDC;" |
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| * '''↑''' PTH
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| * '''''↑''''' Calcium
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| * ''↑ Phosphate''
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| |-
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| | colspan="2" style="background: #F0FFFF; text-align: center;" |Familial hypocalciuric hypercalcemia
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| | style="background: #DCDCDC;"
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| * This is a genetic disorder caused my mutation in calcium-sensing receptor gene.
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| | style="background: #DCDCDC;"
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| * This is a benign condition and does not require treatment.
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| | style="background: #DCDCDC;"
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| * N'''/↑''' PTH
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| * N/'''''↑''''' Calcium
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| | style="background: #DCDCDC;"
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| * Calcium/creatinine clearance ratio
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| |-
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| | rowspan="4" style="background: #F0FFFF; text-align: center;" |'''Malignancy'''
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| | style="background: #F0FFFF; text-align: center;" |Humoral hypercalcemia of malignancy
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| | style="background: #DCDCDC;" |Tumor cells secretes parathyroid hormone related protein (PTHrP) which has similar action as parathyroid hormone.
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| | style="background: #DCDCDC;" |
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| * Most common cause of malignancy related hypercalcemia.
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| * Usually present in solid tumors
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| | style="background: #DCDCDC;" |
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| * '''↑''' PTHrP
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| * '''''↑''''' Calcium
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| * '''↓'''/N P''hosphate''
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| * N/↑ Calcitriol
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| | style="background: #DCDCDC;" |
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| * Chest X-ray
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| * CT scan
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| * MRI
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Osteolytic tumors
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| | style="background: #DCDCDC;" |Multiple myeloma produces osteolysis of bones causing hypercalcemia. Osteolytic metastasis can cause bone resorption causing hypercalcemia.
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| | style="background: #DCDCDC;" |
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| * Most commonly present in multiple myeloma and breast cancer.
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| | style="background: #DCDCDC;" |
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| * '''''↓''''' PTH
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| * '''↑''' Calcium
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| | style="background: #DCDCDC;" |
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| * DXA
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| * X-ray
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| * Mammography
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| * Ultrasound
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| * ESR
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| * Serum protein electrophoresis
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Production of calcitirol
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| | 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.
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| | style="background: #DCDCDC;" |
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| * Most commonly present in lymphomas and in some ovarian germ cell tumors.
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| | style="background: #DCDCDC;" |
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| * '''↑''' Calcium
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| * ↑ Calcitriol
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| | style="background: #DCDCDC;" |
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| * CT scan
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| * MRI
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Ectopic parathyroid hormone
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| | style="background: #DCDCDC;" |Some tumors leads to ectopic production of parathyroid hormone.
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| | style="background: #DCDCDC;" |
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| * In rare instances, small cell carcinoma of lung may produce hypercalcemia by this process.
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| | style="background: #DCDCDC;" |
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| * ↑ PTH
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| * ↑ Calcium
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| * ''↓/N Phosphate''
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| * N/↑ Calcitriol
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| | style="background: #DCDCDC;" |
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| * Chest X-ray
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| * CT scan
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| * MRI
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| |-
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| | rowspan="2" style="background: #F0FFFF; text-align: center;" |'''Medication induced'''
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| | style="background: #F0FFFF; text-align: center;" |Lithium
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| | 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.
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| | style="background: #DCDCDC;" |
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| * History of mood disorder
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| | style="background: #DCDCDC;" |
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| * ↑ PTH
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| * ↑ Calcium
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| | style="background: #DCDCDC;" |
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| * Lithium levels
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Thiazide diuretics
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| | style="background: #DCDCDC;" |Thiazide diuretics lowers urinary calcium excretion and causes hypercalcemia
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| | style="background: #DCDCDC;" |
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| * History of cardiac disorder
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| * Rarely causes hypercalcemia
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| | style="background: #DCDCDC;" |
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| * ↑ Calcium
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| | style="background: #DCDCDC;" | --
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| |-
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| | rowspan="2" style="background: #F0FFFF; text-align: center;" |'''Nutritional'''
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| | style="background: #F0FFFF; text-align: center;" |Milk-alkali syndrome
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| | style="background: #DCDCDC;" |Hypercalcemia is be caused by high intake of calcium carbonate
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| | style="background: #DCDCDC;" |
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| * History of
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| ** High milk intake
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| ** Excess calcium intake for treating:
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| *** Osteoporosis
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| *** Dyspepsia
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| * May lead to metabolic alkalosis and renal insufficiency.
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| | style="background: #DCDCDC;" |
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| * ↑ Calcium
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| | style="background: #DCDCDC;" |
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| * Renal function test
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| |-
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| | style="background: #F0FFFF; text-align: center;" |Vitamin D toxicity
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| | style="background: #DCDCDC;" |Excess vitamin D causes increased absorption of calcium from intestine causing hypercalcemia.
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| | style="background: #DCDCDC;" |
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| * History of:
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| ** Excess intake vitamin D
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| ** Excess milk fortified with vitamin D
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| ** Topical application of vitamin D analogue analogue calcipotriol
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| | style="background: #DCDCDC;" |
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| * '''↑''' Calcium
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| * ↑ Vitamin D (calcidiol and/or calcitriol)
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| | style="background: #DCDCDC;" | --
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| |-
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| | style="background: #F0FFFF; text-align: center;" |'''Granulomatous disease'''
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| | style="background: #F0FFFF; text-align: center;" |Sarcoidosis
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| | style="background: #DCDCDC;" |Hypercalcemia is causes by endogeous production of calcitriol by disease-activated macrophages.
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| | style="background: #DCDCDC;" |
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| * History of:
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| ** Cough
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| ** Dyspnea
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| ** Chest pain
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| ** Tiredness or weakness
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| ** Fever
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| ** Weight loss
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| | style="background: #DCDCDC;" |
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| * '''↑''' Calcium
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| * ↑ Calcitriol
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| * ↑ ACE levels
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| | style="background: #DCDCDC;" |
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| * Chest X-ray
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| * Biopsy
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| |}
| |
| <references /> | | <references /> |