Case Presentation

BY, DR.KALEESWARI
64 Year old male patient has presented to emergency department with severe sudden onset left
loin pain, which is radiating down the left flank to his groin and left testicle.
Pain - Colicky
- Associated with nausea and vomiting
On examination,
Pallor,
Profuse Sweating,
Slight Left Loin Tenderness
Investigations
Complete Blood count
Urea, creatinine Normal
Na, K+

Urine - No protein
- Blood+++

Renal USG Normal urinary tract with no detectable stones

Upon further questioning,
- Increasing forgetfulness and irritability
- Polyuria
- Polydipsia
- Poor performance in office
Polyuria
Polydipsia

Some personality changes ?

Symptoms of renal calculi there is no
USG evidence of calculi
Calcium 3.3mmol/L
P+ 0.6mmol/L
ALP 587 IU/L
PTH raised

Radio Isotope scan Parathyroid adenoma

Finally, Parathyroidectomy was done.

Hypercalcemia
2.65mmol/L on two occasions(after adjustment for albumin conc)

Classification:
Mild - 2.65 3mmol/L
Moderate - 3 3.4mmol/L
Severe - >3.4mmol/L
 Causes
Main:
Primary hyperparathyroidism Malignancy (Breast, Lung, Multiple myeloma)
Less Common:
- Thiazide, Lithium
- Sarcoidosis, TB
- Stage 4 or 5 CKD / Transplantation
- Familial hypocalciuric hypercalcemia
- Pagets disease
- Thyrotoxicosis
Clinical Features
1.Bone Pain, Fractures
2.Neuromusculas, Neuropsychiatric
3. Renal
4. CVS
5.ECG Short QT interval
- Osborn waves or J waves
6. Abdomen
Treatment
- Diagnose and Treat the underlying cause
>3.5mmol/L and Symptomatic
(i) Re hydration IV 0.9% saline
(ii)Bisphosphonates Prevent Bone resorption by inhibiting osteoclast activity
- Pamidronate lowers Ca2+ over 2 to 3 days(30mg in
300ml 0.9% saline over 3 hrs
- Zoledronic acid
SE: Oesophagitis, Flu symptoms, Lymphocytopenia
(iii)Furosemide Promotes renal excretion of Ca2+
(iv)Avoid Thiazides
(v)Further management
- Steroids
- Chemotherapy
PTH
Function:
- Osteoclast activity
- Ca, P reabsorption in Kidney
- Active vitamin D production
Symptoms:
Stones, Bone, Abd groans, Thrones, Psychiatric Overtones
 Investigations
-
- Ca
- Phosphate
- ALP
- Imaging
- Osteitis Fibrosa Cystica
- Pepper Pot Skull
-
- DEXA for Osteoporosis
T Score - Normal ->-1 SD
- Mild -> -1 and -2.5 SD
- Osteoporosis -> at/below -2.5SD
- Tc 99m Sestamibi Scan
-
 - Tc 99m sestamibi is absorbed faster by a
hyperfunctioning parathyroid gland
- Abnormal parathyroid retains its activity,
while the radio pharmaceutical is eluted
out of normal thyroid gland
Treatment
Indications:
- Bone Disease
- Osteoporosis
- Renal function, Renal Calculi
- Age < 50 years
Complications:
- Hypoparathyroidism
- Hungry Bone Syndrome
- RLN Damage
Secondary Hyperparathyroidism
Causes:
- Vitamin D intake
- CRF
Features:
- Ca , P , PTH
Tertiary Hyperparathyroidism:
- After prolonged secondary hyperparathyroidism
- Seen in CRF
- Ca , P , PTH .
Metabolic Causes of Dementia
- Hypothyroidism
- Vitamin B12 deficiency
- Uraemia
- Hypercalcemia
Take Home Message
- Underlying causes of mental disease must be sought and not ascribed to ageing.
- Failure to demonstrate stones does not exclude nephrolithiasis.
Thank you