In: Textbook of Small Animal Orthopaedics, C. D. Newton and D. M. Nunamaker (Eds.

)
Publisher: International Veterinary Information Service (www.ivis.org), Ithaca, New York, USA.
Calcium-Regulating Hormones and Metabolic Bone Disease ( 1-Jan-1985 )
C. C. Capen

! SECTION ONE: THE ROLE OF CALCIUM AND CALCIUM REGULATING HORMONES

! SECTION TWO: METABOLIC BONE DISEASE

SECTION ONE
THE ROLE OF CALCIUM AND CALCIUM-REGULATING HORMONES
! Calcium

! Parathyroid Hormone

! Calcitonin

! Cholecalciferol (Vitamin D)

CALCIUM
Calcium ion plays a key role in many fundamental biologic processes including muscle contraction, blood coagulation,
enzyme activity, neural excitability, hormone release, and membrane permeability, in addition to being an essential structural
component of the skeleton. Therefore, the precise control of calcium ion in extracellular fluids is vital to the health of humans
and animals. To maintain a constant concentration of blood calcium, despite marked variations in intake and excretion,
endocrine control mechanisms have evolved that consist primarily of the interactions of three major hormones. Although the
direct roles of parathyroid hormone (PTH), calcitonin (CT), and vitamin D frequently are emphasized in the control of blood
calcium, other hormones such as adrenal corticosteroids, estrogens, thyroxine, somatotropin, and glucagon may contribute to
the maintenance of calcium homeostasis under certain conditions.

The level of total blood calcium in mammals is approximately 10 mg/dl with some variation due to species, age, dietary
intake of calcium, and analytical method used to quantitate blood levels. The calcium concentration in the blood is composed
of protein-bound and diffusible fractions. Diffusible calcium consists of calcium complexed to anions such as phosphate and
citrate plus the biologically active, "free" (ionized) calcium.

Ionized calcium is the physiologically important fraction, but it is infrequently measured, either because of strict collection
requirements or the unreliability of ion-specific analyzers. In most laboratories only serum total calcium is measured.
Because approximately half of the calcium is protein bound, the interpretation of total calcium depends on the concurrent
values for serum albumin and total protein.(154) In human beings, there are significant linear relationships between serum
total calcium and albumin and between serum total calcium and total protein. Adjustment formulas have been derived for
serum total calcium on the basis of the concentrations of albumin and total protein.(11,155)

The adjustment formulas for calcium have been derived by adding the difference between the y intercept value from the
regression line and the normal mean for serum calcium (10.1 mg/dl) to each intercept value. (127,155) The y intercept for
albumin in dogs was 6.57 and the difference was 3.53. For serum total protein, the y intercept was 6.81 and the difference
was 3.29. The slope of the regression line was multiplied by the absolute value for albumin or serum total protein. The slope
for serum total protein was 0.41, and the slope for albumin was approximately 1, thereby making this step unnecessary.
Therefore, the final adjustment formulas in dogs are as follows(127)

adjusted calcium/ (mg/dl) = measured serum total calcium (mg/dl) - serum albumin + 3.5 (g/dl)

adjusted calcium (mg/dl) = measured serum total calcium(mg/dl)- 0.4(total serum protein) + 3.3 (g/dl)

A positive linear relationship was found between serum total calcium and albumin (Fig. 59-1) for hospitalized dogs (r=0.575;
P < 0.001). One third of the variability in calcium was attributable to the change in the concentration of albumin (R^2=0.33).
In the study reported by Meuten and co-workers,(127) of the 209 dogs studied had a low concentration of serum albumin
(<2.01 g/dl). Of these 14 dogs, 4 (29%) were normocalcemic and 10 (71%) were hypocalcemic (6.9-8.7 mg/dl). After
adjustment of total calcium for albumin concentration, 9 of the 10 hypocalcemic dogs had values of calcium within the
normal range.(127)

FIG. 59-1 Significant relationship between serum albumin and total calcium
concentrations in hospitalized dogs (r=0.575 P<0.001). The least square regression line
(solid line), the 95% confidence limits for the regression line (two broken lines), and
the 95% confidence limits for the population (shaded area) are included in the graph.
The numbers represent the number of values at superimposed points. As the
concentration of albumin increases or decreases, there is a concurrent increase or
decrease in serum total calcium. One third of the variability in calcium was attributable
to the change in the concentration of albumin (R^2 = 0.33) (Meuten DJ, Chew DJ,
Capen CC et al: Relationship of serum total calcium to albumin and total protein in
dogs. J Am Vet Med Assoc 180:63, 1982)

In dogs that had hyperalbuminemia (serum albumin concentrations (>3.7 g/dl), the measured and adjusted concentrations of
serum total calcium were normal. The mean (and range) for serum albumin concentration in the dogs with hyperalbuminemia
was 4 g/dl (3.75.1 g/ dl)

A positive linear relationship has been reported between serum total calcium and serum total protein (Fig. 59-2) for dogs (r =
0.411; P <0.001).(127) Approximately 17% of the variability in calcium was attributable to the change in the concentration of
serum total protein (R^2=0.169). Seventy-three percent of dogs with a low serum total protein concentration (<5.6 g/dl) had a
low serum calcium concentration. After adjustment of total calcium for the concentration of serum total protein, 88% Of the
hypocalcemic dogs had values of calcium within the normal range.(127) Dogs with high concentrations of serum total protein
(>8 g/dl) had normal measured and adjusted calcium values. The mean serum total protein in these dogs was 8.6 g/dl and the
range was 8.0 g-10.8 g/dl. Calcium concentrations >12 mg/dl in dogs were not ascribed to hyperalbuminemia or
hyperproteinemia, and total calcium concentrations <6.5 mg/dl were not attributable to hypoalbuminemia or
hypoproteinemia. (127)

Approximately 90% of dogs with disorders of calcium metabolism and 86% of young dogs (6 to 24 weeks of age) had
calcium values outside the 95% confidence limits calculated for albumin and total protein for hospitalized dogs (Figs. 59-3
and 59-4) (127) Data from 95% of dogs with hypercalcemia of malignancy (i.e., Iymphosarcoma, adenocarcinoma of the
apocrine glands of the anal sac, and giant cell carcinoma of the lung) were outside the 95% confidence limits for albumin and
total protein. Similarly, total serum calcium values in the young dogs were clustered in a relatively uniform group outside the
95% confidence limits. The mean values for young dogs were total calcium 11 mg/dl; albumin 2.7 g/ dl; serum total protein
5.2 g/ dl; and phosphorus 8.4 mg/ dl. Adjusting calcium for albumin resulted in a mean value of 11.9 mg/dl and adjusting for
serum total protein gave a mean calcium value of 12.3 mg/dl. Total serum calcium values in dogs with hypoparathyroidism
and primary hyperparathyroidism were always outside the 95% confidence limits.(127) Seventy-nine percent of the dogs with
renal disease were reported to have calcium values outside the 95% confidence limits for albumin and total protein, but there
often was considerable variation among individual dogs(127)

FIG. 59-2 Significant relationship between total serum protein and total calcium
concentrations in hospitalized dogs. The least square regression line (solid line), the
95% confidence limit for the regression line (two broken lines), and the 95%
confidence limits for the population (shaded area) are included in the graph. The
numbers represent the number of values at superimposed points. Approximately 17% of
the variability in calcium was attributable to the change in the concentration of serum
total protein (R^2=0.169). (Meuten DJ, Chew DJ, Capen CC et al: Relationship of
serum total calcium to albumin and total protein in dogs. J Am Vet Med Assoc 180:63,
1982)

FIG. 59-3 Compared with serum total calcium in hospitalized dogs, 91% of
dogs with disorders of calcium metabolism and 86% of young dogs were
outside the 95% confidence limits for serum albumin. (in hypercalcemia of
malignancy; circle, young dogs (6-24 weeks old); X, renal disease; open
circle. hypoparathyroidism; triangle, primary hyperparathyroidism). (Meuten
DJ, Chew DJ, Capen CC et al: Relationship of serum total calcium to
albumin and total protein in dogs. J Am Vet Med Assoc 180:63, 1982)

FIG. 59-4 Compared with serum total calcium in hospitalized dogs, 91%
of dogs with disorders of calcium metabolism and 86% of young dogs
were outside the 95% confidence limit for serum total protein (a,
hypercalcemia of malignancy; closed circle, young dogs (6 24 weeks old),
X, renal disease; open circle, hypoparathyroidism; triangle, primary
hyperparathyroidism). (Meuten DJ, Chew DJ, Capen CC et al:
Relationship of serum total calcium to albumin and total protein in dogs. J
Am Vet Med Assoc 180:63, 1982)

PARATHYROID HORMONE
EMBRYOLOGY AND MACROSCOPIC ANATOMY OF PARATHYROID GLANDS
Embryologically, parathyroids are of entodermal origin. They are derived from the third and fourth pharyngeal pouches in
close association with primordia of the thymus. The entodermal bud that forms the thyroid gland arises on the midline at the
level of the first; pharyngeal pouch. This gives rise to the thyroglossal duct that migrates caudally. The proliferation of cell
cords at the distal end of the thyroglossal duct forms the follicles of each thyroid lobe. The-area at the base of the tongue
marking the origin of the thyroid gland is referred to as the foramen cecum in postnatal life. Calcitonin-secreting C cells of
neural crest origin reach the postnatal thyroid gland by migrating into the ultimobranchial body. This last pharyngeal pouch
moves caudally in mammals to fuse with the primordia of the thyroid gland and distributes C cells into each thyroid lobe.

Parathyroid glands in most animal species consist of two pairs of glands situated in the anterior cervical region (Fig. 59-5). In
the dog and cat both the external and internal parathyroids are close to the thyroid gland. The external parathyroid (III) in the
dog is from 2 mm to 5 mm in length and is found in the loose connective tissue cranial and slightly lateral to the anterior pole
of the thyroid. The internal parathyroid (IV) is smaller, flatter, and situated on the medial surface of the thyroid beneath the
fibrous capsule. The blood supply of the two glands in the dog is separate. The external parathyroid is supplied by a branch
from the cranial thyroid artery, and the internal parathyroid is supplied by minute ramifications of the arterial supply to the
thyroid.(182)

FIG. 59-5 Anatomical location of parathyroid glands in relation to the thyroid and
related structures in several species of domestic animals. Chief cells interpreted to be in
an inactive (resting or involuted) stage of their secretory cycle predominate in the
parathyroid glands of humans and most animal species. Inactive chief cells are cuboidal
and have uncomplicated interdigitations between contiguous cells. The relatively
electron-transparent cytoplasm contains poorly developed organelles and infrequent
secretory granules (Fig. 59-6). The cytoplasm either has numerous neutral lipid bodies
and lipofuscin droplets or aggregations of glycogen granules (e.g., human and feline
glands). The Golgi apparatus is small, composed of straight or curved agranular
membranes, and is associated with a few prosecretory granules in the process of
formation. Individual profiles of granular endoplasmic reticulum, ribosomes, and small
mitochondria are dispersed throughout the cytoplasm (Fig. 59-6).

FIG. 59-6 Inactive chief cell in the parathyroid gland of a cat. The
cytoplasm contains few secretory granules (S), a small Golgi
apparatus (G), sparse endoplasmic reticulum (ER), scattered
mitochondria (M), and glycogen particles (arrow). The extracellular
perivascular space is bordered by the basement membranes of the
capillary endothelial and chief cells and contains collagen fibers.
(original magnification x 13,900) (Capen CC, Rowland GN: The
ultrastructure of the parathyroid glands of young cats. Anat Rec
162:327, 1968)

FUNCTIONAL CYTOLOGY OF PARATHYROID GLANDS

CHIEF CELLS

FIG. 59-7 Active chief cells in the parathyroid gland from a young
(9-week-old) cat. By comparison, the cytoplasm of chief cells in the
active stage of the secretory cycle contains numerous secretory
granules (S), scattered profiles of rough endoplasmic reticulum
(ER), numerous free ribosomes, Golgi apparatuses (Go associated
with prosecretory granules and vacuoles, and scattered mitochondria
(M). (original magnification x 11,300) (Capen CC, Rowland GN:
The ultrastructure of the parathyroid glands of young cats. Anat Rec
162:327, l968)

Present evidence indicates that the parathyroid glands contain a single basic type of secretory cell concerned with the
elaboration on one hormones The parathyroids of humans and animals are composed of chief cells in various stages of
secretory activity and in transition to oxyphil cells in certain species.(25) Experimental and pathologic evidence has
accumulated to suggest that certain fine structural characteristics of chief cells are associated with different stages of
synthetic and secretory activity (24,170)
Chief cells in the active stage of the secretory cycle occur less frequently in the parathyroid glands of most species under
normal conditions. The cytoplasm of active chief cells has an increased electron density owing to the close proximity of
organelles, numerous secretion granules, overall density of the cytoplasmic matrix, and loss of glycogen particles and lipid
bodies (Fig. 59-7)(170)

OXYPHIL CELLS AND TRANSITIONAL FORMS

A second cell type in the parathyroid glands of certain animal species and humans is the oxyphil cell (Fig. 59-8). Oxyphil
cells are not present in the human fetal parathyroid gland. They first appear in late childhood and increase in number with
advancing age, often forming nodules in parathyroids of older persons.(138) They are absent in parathyroids of the rat,
chicken, and many species of lower animals.(45,69,172)

FIG. 59-8 Oxyphil cell with large cytoplasmic area packed with
numerous mitochondria and containing a small irregular nucleus (N).
These metabolically altered parathyroid cells have a small Golgi
apparatus (G) and few secretory granules (arrow), displaced to the
periphery of the cell by the numerous mitochondria. (original
magnification x 6000)

Oxyphil cells are observed either singly or in small groups interspersed among chief cells. They are larger than chief cells,
and their abundant cytoplasmic area is filled with numerous large, often bizarre-shaped mitochondria (Fig. 59-8). Glycogen
particles and free ribosomes are interspersed among the mitochondria. Granular endoplasmic reticulum, Golgi apparatuses,
and secretory granules are poorly developed in oxyphil cells of normal parathyroid gland,(24) suggesting that oxyphil cells
do not have an active function in the biosynthesis of parathyroid hormone. Associated with the marked increase in
mitochondria, oxyphil cells have been shown histochemically to have a higher oxidative and hydrolytic enzyme activity than
chief cells (Fig. 59-9),(9,83,195)

FIG. 59-9 Histochemical demonstration of enzyme activity in parathyroid cells.

Oxyphils with their abundant mitochondria have greater oxidative and hydrolytic
enzyme activity than in principal (chief) cells and transitional forms. Water-clear cells
represent chief cells following long-term overstimulation ("exhaustion"). Their
expanded cytoplasmic area contains either Golgi apparatusderived vacuoles or
abnormal accumulations of glycogen but few mitochondria and low enzyme activity.
(Harcourt-WebsterJN, Truman RF: Histochemical study of oxidative and hydrolytic
enzymes in the abnormal human parathyroid J Pathol 97:687, 1969)

Cells are observed with cytoplasmic characteristics intermediate between those of chief and oxyphil cells, suggesting that
oxyphil cells represent structurally and functionally modified chief cells. These transitional oxyphil cells have numerous
mitochondria, but other organelles are present, including granular endoplasmic reticulum, Golgi apparatuses, and secretory
granules. The significance of oxyphil cells in the pathophysiology of the parathyroid glands has not been elucidated, but they
do not appear to be active in the synthesis of parathyroid hormone.

Oxyphils are not altered in response to either shortterm hypocalcemia or hypercalcemia in animals,(24) but both oxyphils and
transitional forms may be increased in response to long-term stimulation of human parathyroid glands.(l79) Occasionally
parathyroid adenomas composed predominantly of oxyphil cells and transitional forms have been reported associated with
excessive PTH secretion and a syndrome of primary hyperparathyroidism in humans.(3,l71) The transitional oxyphil cells
that constitute these neoplasms have many large mitochondria in their cytoplasm but a more extensive endoplasmic reticulum
and well-developed Golgi apparatus with more numerous secretory granules than oxyphil cells in normal parathyroid glands.
(7) Therefore, oxyphil cells do not appear to be degenerate chief cells as previously thought but rather are derived from chief
cells as the result of aging or some metabolic derangement.

BIOSYNTHESIS OF PTH
Recent evidence suggests that a larger biosynthetic precursor is first synthesized on ribosomes of the rough endoplasmic
reticulum in chief cells.(6,40,76,78,80,82,109,121,157,179) Pre-proparathyroid hormone (pre-proPTH) is the initial
translational product synthesized on ribosomes. It is composed of 115 amino acids and contains a "signal" or leader sequence
of 25 hydrophobic amino acid residues that may facilitate the penetration and subsequent vectorial discharge of the nascent
peptide into the cisternal space of the rough endoplasmic reticulum(75,89) (Fig. 59-10). Pre-proPTH is rapidly converted
(within one minute or less of its synthesis) to proparathyroid hormone (proPTH) by proteolytic cleavage of the NH2-terminal
sequence of 25 amino acids.(81)

FIG. 59-10 Subcellular compartmentalization, transport, and cleavage of precursors of

parathyroid hormone (PTH). Preproparathyroid hormone (pre-proPTH) is the initial
translation product from ribosomes of the rough endoplasmic reticulum, which is
rapidly converted to pro-parathyroid hormone (proPTH). The hydrophobic sequence on
the amino-terminal end of the pre-proPTH facilitates penetration of the leading portion
of the nascent peptide into the lumen of the endoplasmic reticulum. ProPTH is
transported to the Golgi apparatus where it is converted enzymatically by a
carboxypeptidase (CPase) to biologically active PTH. A major portion of the
biosynthetic precursors and active PTH is degraded by Iysosomal enzymes and is not
secreted by chief cells under normal conditions. Parathyroid secretory protein (PSP)
may function as a binding protein for PTH during intracellular storage in secretion
granules and may be released with PTH into the extracellular space. (Habener JF, Potts
JT Jr: Biosynthesis of parathyroid hormone. N Engl J Med 299 580, 1978)

The intermediate precursor, proPTH, is composed of 90 amino acids and moves within membranous channels of the
endoplasmic reticulum to the Golgi apparatus (Fig. 59-10). Enzymes with trypsinlike and carboxypeptidase B-like activity
within membranes of the Golgi apparatus cleave a hexapeptide from the NH2-terminal (biologically active) end of the
molecule forming active PTH.76 79,122 Active PTH is packaged into membranelimited, macromolecular aggregates in the
Golgi apparatus for subsequent storage in chief cells. Under certain conditions of increased demand, PTH may bypass
packaging in the Golgi apparatus and be released directly from chief cells.

Biologically active PTH secreted by chief cells is a straight-chain polypeptide consisting of 84 amino acid residues with a
molecular weight of approximately 9500 daltons.(19) Molecular fragments (Cand N-terminal) of PTH are formed in the
peripheral circulation, liver, at the target cells of the hormone, and possibly within chief cells. The immunoheterogeneity
created by the multiple circulating fragments of PTH has caused significant problems in the development and application of
highly specific radioimmunoassays to clinical diagnostic problems.(5) Current evidence suggests it is in the Golgi apparatus
that PTH (184 amino acid sequence) is cleaved enzymatically from proPTH and packaged into mature secretory or storage
granules.(40,65) As the Golgi apparatus subsequently involutes, acid phosphatase activity appears in its membranes, and acid
phosphatase-positive lysosomal bodies are formed in the Golgi complex.(177) During the involuting phase the PTH (1-84
amino acid sequence) packaged in granules moves from the Golgi region and is stored in the cytoplasm prior to secretion
from chief cells. Low ambient calcium levels speed up the rate of secretion of PTH and shorten the resting phase of chief
cells; conversely, high ambient calcium levels suppress the rate of hormone secretion and lengthen the resting phase of the
secretory cycle.
STORAGE AND SECRETION OF PTH
Secretory ("storage") granules have been demonstrated readily at the level of ultrastructure within chief cells of the
parathyroid glands in all animal species examined (Fig. 59-11)(2,31,170) Roth and associates(173) localized PTH within
chief cells of bovine parathyroids to the small membrane-limited secretory granules by immunocytochemical techniques
using rabbit antiserum and peroxidase-labeled goat anti-rabbit globulin. The rabbit antiserum used in these studies recognized
multiple antigenic determinants of bovine PTH including the biologically active Nterminal of the molecule. Reaction product
was not deposited over the larger acid phosphatase-positive lysosomal bodies in chief cells.

FIG. 59-11 Mature secretory (storage) granule in the feline

parathyroid gland is surrounded by a closely applied limiting
membrane (arrow) and is composed of fine dense particles.
Secretory granules contain biologically active parathyroid hormone
and parathyroid secretory protein. (original magnification x 315,000)
(Capen CC, Rowland GN: The ultrastructure of the parathyroid
glands of young cats. Anat Rec 162:327, 1968)

Secretory granules in chief cells also contain a parathyroid secretory protein (PSP) in addition to PTH. Kemper and co-
workers(110) reported that bovine parathyroids incubated in vitro secrete a protein that is distinct from both proPTH and
PTH. It is a large protein (two or more subunits of molecular weight 70,000 daltons) and constitutes about 50% of the total
protein secreted by the parathyroid. PSP may accompany PTH in the intracellular transport pathway through cytoplasmic
organelles and is associated predominantly with the particulate fraction of chief cells.(81) Secretion of PSP is stimulated or
inhibited in parallel with that of PTH by varying the concentration of calcium in the incubation medium. The coordinated
secretion of PSP and PTH in response to changes in levels of ambient calcium suggests that both molecules are present in the
membrane-limited secretion granules in chief cells. Although the function of PSP is uncertain at present, it appears to
represent a "binding protein" for PTH and may be analogous in function to the neurophysins secreted with oxytocin and
vasopressin by the neurohypophyseal system.(59)

The PTH-containing secretory granules migrate peripherally in chief cells, and their limiting membrane fuses with the plasma
membrane of the cell. An internal cytoskeleton composed of microtubules and contractile filaments has been reported to be
important in control of the peripheral movement of secretory granules and liberation of secretory products from other
endocrine cells (e.g., beta cells of the pancreatic islets).(116) The presence of peripheral microfilaments in chief cells as well
as the attachment of granules to the plasma membrane by stalklike condensations of cytoplasmic material in some species
suggests that a similar secretory mechanism exists in parathyroid glands.(211)

Secretory granules appear to be extruded from chief cells by exocytosis into perivascular spaces.(24,60,61) Numerous small
spherules of similar size have been observed by scanning electron microscopy to protrude from secretory surfaces of chief
cells into perivascular spaces (Fig. 59-12).(24) Thiele and Wermbter(193) used freeze-fracture techniques to demonstrate
secretory granules being discharged from chief cells by exocytosis in the human parathyroid gland.

FIG. 59-12 Scanning electron micrograph of the secretory surface of

active chief cells in the parathyroid gland illustrating secretory
granules (arrowheads) budding into the perivascular space. Chief
cells are polyhedral, and distinct cell boundaries can be visualized
(arrows). (original magnification x 3000)

CONTROL OF PTH SECRETION

Secretory cells in the parathyroids store relatively small amounts of preformed hormone but are capable of responding to
minor fluctuations in calcium ion concentration by rapidly altering the rate of hormonal secretion(158) and more slowly by
altering the rate of hormonal synthesis.(172) In contrast to most endocrine organs, which are under complex controls, the
parathyroids have a unique feedback control system that relies primarily on the concentration of calcium (and to a lesser
extent magnesium) ion in blood.(4,189) If the blood calcium level is elevated by the intravenous infusion of calcium, there is
a rapid and pronounced reduction in circulating levels of immunoreactive parathyroid hormone (iPTH) (Fig. 59-13).
Conversely, if the blood calcium level is lowered by ethylenediaminetetra-acetic acid EDTA, there is a brisk and substantial
increase in iPTH levels.(145) The concentration of blood phosphorus has no direct regulatory influence on the synthesis and
secretion of PTH; however, certain disease conditions characterized by hyperphosphatemia in both animals and humans are
associated clinically with hyperparathyroidism. An elevated blood phosphorus level may lead indirectly to parathyroid
stimulation by virtue of its ability to lower the blood calcium level according to the mass-law equation when the serum is
saturated with respect to these two ions.(115) If the blood phosphorus level is elevated significantly by an infusion of
phosphate and calcium administered simultaneously in amounts to prevent the accompanying reduction of the blood calcium
level, plasma iPTH levels remain within the normal range. In addition, hyperphosphatemia suppresses the rate of formation
of the biologically active, hormonal form of vitamin D (1,25dihydroxycholecalciferol 1,25-diOH-CC) in the kidney, which
further contributes to the development of hypocalcemia and parathyroid stimulation.

FIG. 59-13 Changes in immunoreactive parathyroid hormone in

response to hypercalcemia induced by calcium infusion,
hypocalcemia produced by EDTA infusion, and hyperphosphatemia
with normocalcemia. (Aurbach GD, Potts JT Jr: Parathyroid
hormone. Am J Med 42:1, 1967)

Magnesium ion has an effect on PTH secretory rate similar to that of calcium but not equipotent.(124,134) The more potent
effects of calcium ion in the control of PTH secretion together with its preponderance over magnesium in the extracellular
fluid suggest a secondary role for magnesium in parathyroid control.

Calcium ion controls not only the rates of biosynthesis and secretion of PTH but also other metabolic and intracellular
degradative processes within chief cells.(37,38) An increased calcium ion concentration in extracellular fluids rapidly inhibits
the uptake of amino acids by chief cells, synthesis of proPTH and conversion to PTH, and secretion of stored PTH. The
shifting of the percent of flow of proPTH from the degradative pathways to the synthetic route represents a key adaptive
response of the parathyroid gland to a low-calcium diet.(37,38) Parathyroids from rats fed a low-calcium (0.02%) diet
convert approximately 40% of proPTH to PTH compared with a 20% conversion in rats fed a control diet. During periods of
long-term calcium restriction, the enhanced synthesis and secretion of PTH would be accomplished by an increased capacity
of the entire pathway in individual chief cells and through hyperplasia of active chief cells.(40) Recently synthesized and
processed active PTH may be released directly in response to increased demand and bypass the chief cell's storage pool of
mature secretory granules in the cytoplasm. Bypass secretion of calcium can be stimulated only by a low circulating
concentration of calcium ion and not by other secretagogues for PTH (Fig. 59-14). Degradation of "mature PTH" by
lysosomal enzymes occurs after prolonged exposure of chief cells to a highcalcium environment.

FIG. 59-14 Bypass secretion of parathyroid hormone in response to increased demands

signaled by a decreased blood calcium ion concentration. Recently synthesized and
processed active PTH (1-84) may be released directly and not enter the chief cell's
storage pool of mature ("old") secretory granules in the cytoplasm. Parathyroid
hormone from the storage pool can be mobilized by cyclic adenosine monophosphate
(cAMP), ,B-agonists (such as epinephrine, norepinephrine, and isoproterenol), as well
as by lowered blood calcium ion, whereas secretion from the pool of recently
synthesized PTH can be stimulated only by a decreased calcium ion concentration.
(Cohn DV, MacGregor RR: The biosynthesis, intracellular processing, and secretion of
parathormone. Endocrine Rev 2:1, 1981)
BIOLOGIC ACTION OF PTH
PTH is the principal hormone involved in the minute-to-minute fine regulation of blood calcium in mammals.(4) It exerts its
biologic actions by directly influencing the function of target cells primarily in bone and kidney, and indirectly in the
intestine, to maintain plasma calcium at a level sufficient to ensure the optimal functioning of a wide variety of body cells.

The action of PTH on bone is to mobilize calcium from skeletal reserves into extracellular fluids. The administration of PTH
causes an initial decline followed by a sustained increase in circulating levels of calcium. This transitory decrease in the
blood calcium level is considered to be the result of a sequestration of calcium phosphate in bone and soft tissues(153) The
subsequent increase in the blood calcium level results from a direct or indirect interaction of PTH with osteoblasts, osteocytes
and osteoclasts in bone.

The response of bone to PTH is biphasic. The immediate effects are the result of increasing the activity of existing osteoclasts
and osteocytes present in bone. This rapid effect of PTH depends upon the continuous presence of hormone and results in an
increased flow of calcium from deep in bone to bone surfaces through the coordinated action of osteocytes and endosteal
lining cells (inactive osteoblasts) (Fig. 59-15). This osteocyte-osteoblast "pump" is concerned with movement of calcium
from the bone fluid to the extracellular fluid compartment.

FIG. 59-15 Parathyroid hormone-responsive osteocyte-

osteoblast "pump" is formed by the fusion of processes of
endosteal lining cells (C, inactive osteoblast) and osteocytes
(D) embedded in cortical bone (F). This functional cellular
syncytium provides a mechanism for transcellular transport of
calcium from the bonefluid compartment around the osteocyte
(E) to the extracellular fluid compartment (B) and capillaries
(A).

The late effects of PTH on bone are potentially of a greater magnitude of response and are not dependent upon the continuous
presence of hormone. Osteoclasts appear to be primarily responsible for the long-term action of PTH by increasing bone
resorption and overall bone remodeling. This is interesting in light of recent findings which have failed to demonstrate
receptors for PTH on osteoclasts but receptors were present on osteoblasts. If the increase in PTH is sustained, the active
osteoclast pool in bone is increased by activation of osteoprogenitor cells in the endosteal and other bone-cell envelopes and
recruitment of circulating mononuclear macrophages.(l63,l64) The plasma membrane of osteoclasts in intimate contact with
the resorbing bone surface is modified to form a series of membranous projections, referred to as the brush ("ruffled") border
(Fig. 59-16). This area of active bone resorption is isolated from the extracellular fluids by adjacent transitional ("sealing")
zones, thereby localizing the Iysosomal enzymes and acidic environment to the immediate area undergoing dissolution. The
mineral and organic components (e.g., hydroxyproline) released from bone are phagocytized by osteoclasts and moved across
the cell in transport vesicles to be released into the extracellular fluid compartment.

A long-term increase in PTH secretion also may result in the formation of greater numbers of osteoblasts with a resultant
increase in osteoid formation as well as resorption. However, resorption is usually greater than formation, leading to a net
negative skeletal balance.

PTH has a rapid (within 5 to 10 minutes) and direct effect on renal tubular function, leading to decreased reabsorption of
phosphate and phosphaturia. The site of action of PTH on blocking tubular reabsorption of phosphate has been localized to
the proximal tubule of the nephron. In addition, PTH leads to an increased urinary excretion of potassium, bicarbonate,
sodium, cyclic adenosine monophosphate, and amino acids.
Although the effect of PTH on the tubular reabsorption of phosphate has been considered to be of major importance,
evidence has accumulated recently suggesting that the ability of PTH to enhance the renal absorption of calcium is of
considerable importance in the maintenance of calcium homeostasis. This effect of PTH upon tubular reabsorption of calcium
appears to be due to a direct action on the distal convoluted tubule. The urinary excretion of magnesium, ammonia, and
titratable acidity also is decreased by PTH. The other important effect of PTH on the kidney is in the regulation of the
conversion of 25-hydroxycholecalciferol (25-OHCC) to biologically active 1,25-DiOH-CC and other metabolites of vitamin
D.
PTH is secreted continuously from chief cells under normal conditions. In the liver, peripheral circulation, and at target cells,
PTH (1-84 amino acid sequence) is cleaved into a smaller (approximately l/3 of molecule) amino (N-) terminal fragment
(biologically active portion) and a larger carboxyl (C-) terminal fragment (biologically inactive portion). 102 The kidney also
is a major organ for the degradation of PTH. Biologically active PTH from peritubular capillaries is degraded by specific
proteases on the surface of renal tubular cells. In addition, both biologically active (NH2Ñ34) and inactive (34Ñ84 COOH)
fragments may be degraded intracellularly by lysosomal enzymes within renal tubular cells.

FIG. 59-16 Osteoclastic osteolysis on a bone surface (S) with release of calcium and
phosphorus into the extracellular fluid. The brush ("ruffled") border (B) is a specialized
area of the plasma membrane of the osteoclast that is in intimate contact with the
underlying bone mineral (S). Adjacent transitional ("sealing") zones isolate the area of
bone surface undergoing active resorption and provide a mechanism for localizing the
Iysosomal enzymes and acidic environment required for the dissolution of bone
mineral. (Fetter AW, Switzer WP, Capen CC: Electron microscopic evaluation of bone
cells in pigs with experimental Bordetella rhinitis [turbinate osteoporosisl. Am J vet Res
36:15, 1975)

SUBCELLULAR MECHANISM OF ACTION OF PTH

The calcium-mobilizing and phosphaturic activities of PTH appear to be mediated through the intracellular accumulation of
3',5'adenosine monophosphate (cAMP) and cytosol calcium in target cells.l61 Binding of PTH to specific receptors on target
cells results in the activation of adenylate cyclase in the plasma membrane (Fig. 59-17). The adenylate cyclase catalyzes the
conversion of ATP to cAMP in target cells. Cyclic 3',5'-AMP accumulation in target cells functions as an intracellular
mediator or second messenger of PTH action, resulting in an increased permeability for calcium ion. The resultant increase in
cytosol calcium content in combination with the cAMP accumulation initiates the synthesis and release of lysosomal
enzymes and triggers other biochemical reactions in osteolytic cells that result eventually in breakdown of both the inorganic
and organic phases of bone.(162)

FIG. 59-17 Mechanism of parathyroid hormone action. The biologically active end of
the hormone (PTH 1-34) binds to specific receptors (R) on the surface of target cells.
The receptorhormone complex is coupled to the catalytic subunit of adenylate cyclase
in the cell membrane by a nucleotide regulatory (N-) protein. This results in the
intracellular accumulation of cyclic adenosine monophosphate (cAMP), which serves
as the "second messenger" for polypeptide hormones such as PTH in target cells and
results in expression of the biologic response of the hormone.

PTH also contributes to the regulation of the rate of formation of 1,25-DiOH-CC, the principal metabolically active form of
vitamin D3, by kidney mitochondria.(48) The active metabolites of vitamin D make bone cells more sensitive to the direct
effects of PTH ("permissive effect") and greatly enhance the gastrointestinal absorption of calcium, thereby amplifying the
effect of PTH upon plasma calcium concentration.(l63 ,164)
CALCITONIN
Calcitonin (thyrocalcitonin, CT) was discovered by Copp and coworkers(44) in experiments designed to test the McLean-
Urist hypothesis of negative feedback control of blood calcium by PTH. They perfused the parathyroid-thyroid complex of
dogs with alternating intervals of blood with low and high calcium concentrations and measured the effects on calcium levels
in peripheral blood (Fig. 59-18). Two findings from these experiments were difficult to explain based upon the existing
concept of a single hormone controlling the concentration of blood calcium. First, the fall in systemic calcium levels
following perfusion of the thyroid-parathyroid complex with high calcium concentrations was more rapid and of greater
magnitude than expected from only an inhibition of PTH secretion. Second, thyro-parathyroidectomy following the last low-
calcium perfusion resulted in a continued progressive rise in blood calcium levels rather than the expected fall after removal
of the source of PTH. These and subsequent experiments lead to development of the concept of a second calcium-regulating
hormone secreted by the parathyroid-thyroid complex in response to hypercalcemia that lowered the plasma calcium
concentration.

FIG. 59-18 Experiment of Copp and associates that led to the discovery of calcitonin.
Perfusion of the thyroid-parathyroid complex in dogs with a high calcium concentration
in the blood resulted in a more rapid and greater decline in peripheral calcium
concentration than was expected by the inhibition of PTH secretion alone.
Thyroidectomy following the last calcium infusion resulted in a progressive
hypercalcemia rather than the expected decline in blood calcium following removal of
the source of PTH. (copp DH, Cameron EC, Cheney BA et al: Evidence for calcitonin:
A new hormone from the parathyroid that lowers blood calcium. Endocrinology 70:638,
1962)

C CELLS IN THYROID
CT has been shown to be secreted by a second endocrine cell population in the mammalian thyroid gland. C (parafollicular)
cells are distinct from follicular cells in the thyroid, which secrete thyroxine and triiodothyronine.(105) They are situated
either within the follicular wall between follicular cells (Fig. 59-19) or as small groups of cells between follicles. C cells do
not border the follicular colloid directly, and their secretory polarity is oriented toward the interfollicular capillaries. The
distinctive feature of C cells is the presence of numerous small membrane-limited secretory granules in the cytoplasm (Fig.
59-19). Immunocytochemical techniques have localized the CT activity of C cells to these secretory granules.(46)

FIG. 59-19 Electron micrograph illustrates a C cell in the wall of a

thyroid follicle wedged between several follicular cells. The
cytoplasm of the C cell has many calcitonin-containing secretion
granules (s) and a prominent Golgi apparatus (G) for the packaging
of hormone. Follicular cells (F) line the follicle and extend microvilli
(arrow) into the colloid (c). The secretory polarity of C cells is
directed toward interfollicular capillaries (E) rather than toward the
follicular lumen, as is that of follicular cells. (original magnification
x 7700)
CHEMISTRY
CT is a polypeptide hormone composed of 32 amino acid residues arranged in a straight chain with a 1-7 disulfide linkage.43
It is a smaller molecule than PTH (84 amino acids) and there is evidence that CT is synthesized as part of a larger
procalcitonin molecule as described with proPTH. The complete sequence of 32 amino acids and the disulfide bond are
essential for full biologic activity of CT. The structure of CT differs considerably among species. For example, the CT
molecules of five selected animal species share only 9 of the 32 amino acid residues (Fig. 59-20). Radioimmunoassays to
measure circulating levels of CT, therefore, are highly species-specific.

FIG. 59-20 Amino acid sequence of the calcitonin

molecule from five species The nine residues in the
chain of 32 amino acids shared by the calcitonin
molecule in all five species are indicated by the
vertical bars. (Foster GV, Byfield PGH,
Gudmundsson TV: Calcitonin. Clin Endocrinol Metab
1:93 124, 1972)

REGULATION OF CT SECRETION
The concentration of calcium ion in plasma and extracellular fluids is the principal physiologic stimulus for the secretion of
CT by C cells.(43) CT is secreted continuously under conditions of normocalcemia, but the rate of secretion of CT is
increased greatly in response to elevations in blood calcium levels. Magnesium ion concentration has an effect on CT
secretion similar to that of calcium, but these effects are observed only under experimental conditions with nonphysiologic
levels of magnesium. Substantial amounts of CT are stored in the cytoplasm of C cells in the form of membrane-limited
secretory granules (see Fig. 59-19). In response to hypercalcemia there is a rapid discharge of stored hormone from C cells
into interfollicular capillaries (Fig. 59-21).(33,210) If the hypercalcemic stimulus is sustained, this is followed by an
increased development of cytoplasmic organelles concerned with the synthesis and secretion of CT (Fig. 59-22). Hyperplasia
of C cells occurs in response to long-term hypercalcemia.(41,146) When the blood calcium level is lowered, the stimulus for
CT secretion is diminished and numerous secretory granules accumulate in the cytoplasm of C cells.

FIG. 59-21 Degranulated C cell within the follicular wall of the

thyroid gland of an animal receiving pharmacologic doses of vitamin
D. The cytoplasmic area of the degranulated C cells is reduced and
depleted of secretory granules but contains a small Golgi apparatus
(G) and scattered mitochondria (M). An intervening rim of follicular
cell cytoplasm separates the C cell from colloid (C) of the thyroid
follicle. An interfollicular capillary (CP) is present at the right. (N.
nucleus) (original magnification x 11,000) (Young DM, Capen CC:
Fine structure of parafollicular cells of cows fed a calcium-deficient
diet and vitamin D. Virchows Arch Abt B Zellpath 8:288, 1971)

The storage of large amounts of preformed hormone in C cells and rapid release in response to moderate elevations in blood
calcium levels probably are a reflection of the physiologic role of CT as an "emergency" hormone to protect against the
development of hypercalcemia. CT secretion is increased in response to a high-calcium meal often before a significant rise in
the plasma calcium level can be detected. The cause of this increase in CT secretion could be due either to a small
undetectable rise in plasma-ionized calcium or to a direct stimulation of certain gastrointestinal hormones by the oral calcium
load, which in turn act as secretagogues for CT release from the thyroid gland (Fig. 59-23) (42) Gastrin, pancreozymin, and
glucagon all have been demonstrated to stimulate CT release under experimental conditions in animals.(34) These findings
suggest that gastrointestinal hormones may be important in triggering the early release of CT to prevent the development of
hypercalcemia following ingestion of a high-calcium meal.(74)
 FIG. 59-22 Hypertrophied C cell wedged between follicular cells (F) in the thyroid
gland of an animal fed a high-calcium (150 g/day) diet for 60 days prepartum. In
response to the high calcium intake, the abundant cytoplasmic area of the C cell
contains numerous clusters of free ribosomes (arrows), prominent Golgi complexes (G)
with prosecretory granules (arrowheads), and large mitochondria. Mature secretory
granules (s) are few in number and concentrated along the plasma membrane adjacent
to the basement membrane of the follicle. (original magnification x 8400) (Black HE,
Capen CC, Yarrington JT et al: Effect of a high calcium prepartal diet on calcium
homeostatic mechanisms in thyroid glands, bone, and intestine of cows. Lab Invest
20:427, 1973)

FIG. 59-23 The gastrointestinal hormone-thyroid C-cell axis

provides a mechanism for rapid release of calcitonin from the
thyroid in response to a high-calcium diet before a significant
elevation in blood calcium occurs.

PHYSIOLOGIC SIGNIFICANCE OF CT
The administration of CT or stimulation of endogenous secretion results in the development of varying degrees of
hypocalcemia and hypophosphatemia. These effects of CT on plasma calcium and phosphorus levels are most evident in
young animals or in older animals with increased rates of skeletal remodeling. CT exerts its function by interacting with
target cells primarily in bone and kidney, and to a much lesser extent, the intestine.

The actions of PTH and CT on bone resorption are antagonistic (both osteocytic and osteoclastic osteolysis), but their actions
on decreasing the renal tubular reabsorption of phosphorus are synergistic. The hypocalcemic effects of CT are primarily the
result of decreased entry of calcium from the skeleton into plasma owing to a temporary inhibition of PTH-stimulated bone
resorption.(1,68) The hypophosphatemia develops as the result of a direct action of CT, which increases the rate of
movement of phosphate out of plasma into soft tissue and bone; it is also the result of inhibition of bone resorption. The
action of CT is not dependent on vitamin D, since it acts both in vitamin D-deficient animals and following the
administration of large doses of vitamin D.

Specific structural alterations are produced in osteoclasts by CT. Osteoclasts withdraw from resorptive surfaces, and the
brush border and transitional zone become atrophic. (107,204) In addition, there is a decrease in the rate of activation of
osteoprogenitor cells to preosteoclasts and osteoclasts, resulting in fewer osteoclasts in bone. Although CT can block bone
resorption completely, the inhibition is a transitory effect. The continuous administration of CT in vivo and in vitro in the
presence of PTH leads to an "escape phenomenon" whereby the effects of PTH on increasing bone resorption become
manifest in the presence of CT.(68)

CT and PTH both decrease renal tubular reabsorption of phosphate, leading to phosphaturia; however, the adenylate cyclase-
linked receptors for CT are found in the ascending limb of Henle and distal convoluted tubule. In addition, CT results in
diuresis of sodium, chloride, and calcium, whereas PTH infusion leads to renal retention of calcium and hydrogen ions. (163)

CT and PTH provide a dual negative feedback-control mechanism to maintain the concentration of calcium in extracellular
fluids within narrow limits. Present evidence suggests that PTH is the major factor concerned with the minute-to-minute
regulation of blood calcium levels under normal conditions. This probably is related to the fact that in most higher mammals,
living in a relatively low calcium-high phosphorus environment, protection against the development of hypocalcemia by PTH
is a life-sustaining function. CT appears to function more as an emergency hormone to prevent the development of
hypercalcemia during the rapid postprandial absorption of calcium, and to protect against excessive loss of calcium and
phosphorus from the maternal skeleton during pregnancy.

CHOLECALCIFEROL (VITAMIN D)
Cholecalciferol is the third major hormone involved in the regulation of calcium metabolism and skeletal remodeling.
Although cholecalciferol has been considered to be a vitamin for a long time, recent evidence suggests it can correctly be
considered a hormone."' Cholecalciferol is ingested in small amounts in the diet and can be synthesized in the epidermis from
precursor molecules (e.g., 7-dehydrocholesterol) through a previtamin D3 intermediate form (Fig. 59-24).(99,101) This
reaction is catalyzed by ultraviolet irradiation (wavelength 290-320 nm) from the sun. A high affinity vitamin D-binding
protein (DBP) transports cholecalciferol from the skin into the blood(97,98)

FIG. 59-24 Photochemical conversion of 7-dehydrocholesterol to

previtamin D3 in the epidermis following exposure to ultraviolet
radiation from sunlight. Previtamin D; subsequently undergoes thermal
conversion to vitamin D3 (cholecalciferol), which enters dermal
capillaries and binds to a specific vitamin D3 binding protein (DBP).
Protein-bound vitamin D3 is transported to the liver for the initial step
of metabolic activation. (Holick MF: J Invest Dermat 76:51, 1981)

In response to prolonged exposure to sunlight, previtamin D3 is converted to lumisterol and tachysterol (Fig. 59-25). Because
the DBP has no affinity for lumisterol and minimal affinity for tachysterol, the translocation of these photoisomers into the
circulation is negligible, and they are sloughed off with the natural turnover of the skin.(96)

FIG. 59-25 Prolonged exposure to sunlight results in the

photochemical conversion of previtamin D3 to lumisterol and
tachysterol. These photoisomers remain primarily in the
epidermis and are lost with the natural turnover of the skin,
since the vitamin D rebinding protein has a low affinity for
these isomers. (Holick MF: J Invest Dermat 76:51, 1981)

METABOLIC ACTIVATION OF VITAMIN D

Vitamin D must be metabolically activated before it can produce its known physiologic functions in target cells.(48-50,112)
Vitamin D3 from dietary sources is absorbed by facilitated diffusion and bound to an a2-globulin in the blood for transport.
Endogenous cholecalciferol synthesized in the skin from 7-dehydrocholesterol also is bound to an a2-globulin for transport to
the liver.

The first step in the metabolic activation of vitamin D is the conversion of cholecalciferol to 25-OH-CC in the liver (Fig. 59-
26).(96) The enzyme responsible for controlling this reaction is the hepatic microsomal enzyme, calciferol-25-hydroxylase,
associated with the endoplasmic reticulum.(12) Considerably larger amounts of protein-bound 25-OH-CC circulate than with
the more hydroxylated metabolites such as 1,25-DiOH-CC, which are present in extremely low levels in the blood.

This first metabolite of cholecalciferol (25-OH-CC) is transported to the kidney and undergoes further transformation to a
more polar and active metabolite(84) (Fig. 59-26). The principal active metabolite of 25-OH-CC formed in the kidney is
1,25-DiOH-CC, but other metabolites are formed such as 24,25-DiOH-CC and 1,24,24TriOH-CC. (18,51,52,140,142) The
rate of formation of 1,25 DiOH-CC is catalyzed by 25-hydroxycholecalciferol-lahydroxylase in renal mitochondria, primarily
in proximal convoluted tubules (Fig. 59-27).(21,l32) The conversion of 25-OH-CC to 1,25-DiOH-CC is the rate-limiting step
in vitamin D metabolism and is the primary reason for the delay between vitamin D administration and expression of its
biologic effects.(73)
 FIG. 59-26 Two-step metabolic activation of cholecalciferol (vitamin D3) beginning in
the liver to form 25hydroxycholecalciferol. This first metabolite is subsequently
released from the liver and transported in a protein-bound form to the kidney, where it
is converted to 1,25-dihydroxycholecalciferol (its principal biologically active
metabolite) and several other metabolites. (Norman AW: Vitamin D: The Calcium
Homeostatic Steroid Hormone. New York, Academic Press, 1979)

FIG. 59-27 The conversion of 25-hydroxycholecalciferol to

1,25dihydroxycholecalciferol is catalyzed by the rate-
limiting enzyme, 25-hydroxy-1-a-hydroxylase present in
mitochondria of cells in the proximal convoluted tubule. This
is the major point of control for the metabolic activation of
vitamin D3.

The control of this final step in the metabolic activation of vitamin D is complex and appears to be regulated in part by the
plasma calcium concentration and its influence on the rates of secretion of PTH(67,77,165) (Fig. 59-28). PTH and conditions
that stimulate its secretion (e.g., low blood calcium levels) increase the transformation of 25-OH-CC to 1,25-DiOH-CC. Low
blood phosphorus levels increase the formation of 1,25-DiOH-CC, whereas high blood phosphorus levels suppress the
activity of the la-hydroxylase (Fig. 59-28).
FIG. 59-28 The rate of conversion of 25-
hydroxycholecalciferol to 1,25-dihydroxycholecalciferol by
the la-hydroxylase is enhanced by parathyroid hormone and
conditions (e.g., low blood calcium levels) that increase its
secretion. Low levels of blood phosphorus and certain other
hormones (e.g., growth hormone estradiol, and prolactin) also
may increase the formation of the biologically active
metabolite of vitamin D under certain conditions.

FIG. 59-29 Negative feedback control exerted by vitamin D

metabolites on parathyroid cheif cells to decrease the rate of
parathyroid hormone secretion, which in turn diminishes the rate
of formation of additional 1,25-dihydroxycholecalciferol.
(Norman AW: vitamin D: The calcium Homeostatic Steroid
Hormone. New York, Academic Press, 1979).

The rates of synthesis of 24,25-DiOH-CC and 1,25DiOH-CC appear to be reciprocally related and controlled by similar
factors.(48,5l-53) When 1,25-DiOH-CC synthesis increases, the synthesis of 24,25DiOH-CC declines and vice versa (see
Fig. 59-26).(l88) In certain animal species 24,25DiOH-CC may play a role in bone formation,(151) egg hatchability,(91) and
with 1,25-DiOH-CC may exert negative feedback control on the parathyroid gland. (17,54,133,203) The parathyroids
selectively localize 1,25-DiOH-CC and contain specific cytoplasmic and nuclear receptors for the active metabolite of
vitamin D. (103) Under experimental conditions, the administration of either 1,25-DiOH-CC or cholecalciferol decreases
parathyroid weight and the DNA content of stimulated glands, but lower doses of 1,25-DiOH-CC require 24,25-DiOH-CC to
lower parathyroid weight significantly in vitamin D-deficient chicks.(30,92) Therefore, a negative feedback loop appears to
exist whereby vitamin D metabolites (either alone or in combination) directly interact with parathyroid chief cells to diminish
the secretion of PTH, which in turn diminishes the formation of 1,25-DiOH-CC (Fig. 59-29).
Other hormones may increase the activity of renal la-hydroxylase and the formation of 1,25-DiOH-CC under certain
conditions. Prolactin, estradiol, and possibly somatotropin enhance 1ahydroxylase activity (see Fig. 59-28).(l23) Increased
secretion of these hormones, either alone or in combination, appears to be important in the efficient adaptation to the major
calcium demands during life (e.g., growth, lactation, and pregnancy).

CHEMISTRY
The chemical structure of cholecalciferol (vitamin D3) resembles other steroid hormones. It is secosteroid in which one of the
rings of the basic steroid nucleus has undergone fission by breakage of a carbon-carbon bond. (141) Photoactivation by
ultraviolet irradiation (290-320 nm) of 7-dehydrocholesterol in the skin results in a cleavage between the 9 and 10 carbons
and unfolding of the B ring of the basic steroid nucleus (see Fig. 59-24).(88,96,100) During metabolic activation of
cholecalciferol, hydroxyl groups are attached successively to the steroid nucleus by specific hydroxylases at positions 25 and
1 in the liver and kidney to form the hormonal or biologically active form of vitamin D.

There are a number of other sterols closely related to cholecalciferol. Vitamin D2 is formed by the irradiation of the plant
sterol referred to as ergosterol. When irradiated ergosterol is ingested and absorbed from the intestine, it undergoes a series of
steps of metabolic activation similar to those described for cholecalciferol. Another related sterol of considerable therapeutic
interest is dihydrotachysterol. The A ring of the steroid nucleus in this compound is rotated so that the hydroxyl in position 3
occupies a position sterically equivalent to the hydroxyl position 1 of 1,25-DiOH-CC. Current evidence suggests the
dihydroxytachysterol undergoes metabolic transformation to 25-dihydrotachysterol, but subsequent hydroxylation of position
1 does not occur.< P>

SUBCELLULAR MECHANISM OF ACTION OF ACTIVE VITAMIN D METABOLITES

Vitamin D and its active metabolites function to increase the absorption of calcium and phosphorus from the intestine,
thereby maintaining adequate levels of these electrolytes in the extracellular fluids in order to permit the appropriate
mineralization of bone matrix.(150) From a functional point of view, vitamin D can be thought to act in such a way as to
cause the retention of sufficient mineral ions to ensure the mineralization of bone matrix, whereas PTH maintains the proper
ratio of calcium to phosphate in extracellular fluids.

FIG. 59-30 Molecular mechanism of action of 1,25-dihydroxycholecalciferol in the

intestine. The active metabolite of vitamin D is transported to the intestine by a vitamin
D-binding protein (DBP). The hydrophilic steroid penentrates the plasma membrane,
binds to a cytoplasmic receptor, and is transported to the nucleus, where it interacts
with the nuclear chromatin to increase the formation of mRNA. The mRNA becomes
associated with ribosomes on the endoplasmic reticulum and directs the synthesis of
new proteins , such as calcium binding protein (CABP). The CABP is involved in the
transcellular transport of calcium to the basilar aspects of the intestinal absorptive cells
where calcium ion is exchanged for sodium and enters the extracellular fluid
compartment.

The major target tissue for 1,25-DiOH-CC is the mucosa of the small intestine where it increases the active transcellular
transport of calcium (proximal part) and phosphorus (distal part). Following synthesis in the kidney, 1,25-DiOH-CC is
transported by a DBP to specific target cells in the intestine (Fig. 59-30) and bone. Free 1,25-DiOH-CC penetrates the plasma
membrane of target cells and initially binds to cytoplasmic receptors in cells of the intestine (Fig 59-30)(20) Subsequently ,
the hormone receptor complex is transferred to the nucleus and 1,25-DiOH-CC binds to specific receptors in the nuclear
chromatin. Here it stimulates gene expression with increased messenger ribonucleic acid (mRNA) formation, which directs
the synthesis of vitamin D-dependent proteins such as calcium binding protein (CaBP cholecalcin) and calcium ATPase by
intestinal cells.(87,201)

Intestinal absorptive cells are responsive to 1,25-DiOH-CC and are concerned with the transport of calcium from the lumen
to the blood stream. The luminal surface (brush border) of absorptive cells is highly specialized and has numerous microvilli,
which greatly increase the intestinal surface area (Fig 59-31) In response to 1,25-DiOHCC, intestinal absorptive cells
synthesize a specific CaBP.(192,200) The highest concentration of CaBP in absorptive cells is in the cytosol near the terminal
web and in the basal cellular region. (194) CaBP in mammals has a molecular weight of between 24,000 daltons and 28,000
daltons and has been isolated from several tissues (eg., small intestine, kidney, parathyroid gland, and the shell gland of
laying hens) across which significant amounts of calcium are transported. In addition, vitamin D-dependent CaBP has been
demonstrated in bone, particularly in the spongiosa and cartilaginous growth plate.(36)

FIG. 59-31 Scanning electron micrograph of epithelial lining in small

intestine illustrates absorptive and goblet cells. The surface of the tall
intestinal absorptive cells (N, nucleus) has numerous microvilli(V)
projecting into the intestinal lumen(L) and numerous large
mitochondria in the cytoplasm. The intestinal absorptive cells are
responsive to the active metabolite of vitamin D and are responsible for
the transport of calcium from the lumen to the capillaries at the basilar
aspect of the cell. A goblet with large granules (S) opens into the lumen
(arrow) between two intestinal absorptive cells.

The absorptive capacity of the intestine for calcium is a direct function of the amount of CaBP present (104,201) The
administration of vitamin D or feeding low-calcium diets has been shown to stimulate the synthesis of CaBP, which
contributes to the increased intestinal absorption of calcium. The physiologic functions of CaBP appear to be related to the
transcellular transport of calcium from the luminal to basilar border of intestinal absorptive cells and the regulation
intracellular calcium concentration.(194) At the basilar aspect of intestinal absorptive cells, calcium is exchanged for sodium
and enters the extracellular fluids.

In addition to this effect on mineralization of bone matrix, vitamin D is necessary for osteoclastic resorption and calcium
mobilization from bone in adults. Small amounts of vitamin D or its active metabolite are necessary to permit osteolytic cells
to respond to PTH (permissive effect) under physiologic conditions. Both 1,25-DiOH-CC(206) and 25-OH-CC and
cholecalciferol in pharmacologic doses will stimulate osteoclastic mobilization of bone calcium and the resorption of bone.
On a weight basis 1,25-DiOH-CC and cholecalciferol in pharmacologic doses will stimulate osteoclastic mobilization of bone
calcium and the resorption of bone. On a weight basis 1,25-DiOH-CC is about 100 times more potent in stimulating bone
resorption in vitro than 25-OH-CC (160,167)

Adult intact female dogs administered intermittent low doses of 1,25-DiOH-CC (1,25 ug daily for 6 days and withdrawn for
14 days for 3 complete cycles) had elevations in levels of blood calcium and phosphorus and increased urinary
hydroxyproline excretion.(93,94) In cortical bone (11th rib) there was a mixed decrease in activation frequency, bone
formation rate, osteoid seam thickness, seam circumference, and mean appositional rate. Although recruitment of new
remodeling sites was decreased after administration of 1,25-DiOH-CC, previously existing remodeling units continues to
completion. These effects resulted in a preponderance of mature osteons in normal cortical bone.(94)(94) In trabecular bone
of the iliac crest in dogs, 1-25-DiOH-CC stimulated the resorption rate and depressed the formation rate. (93) Trabecular
resorption surfaces, osteoid volume and thickness, and mineralization lagtime were decreased by administration of 1,25-
DiOH-CC localizes in the nucleus of tubular cells (185,186) Vitamin D-dependent CaBP is present primarily in cells of the
distal convoluted tubule in most animal species.(191)
SECTION TWO
METABOLIC BONE DISEASE
! Secondary Hyperthyroidism

! Primary Hyperthyroidism

! Hypercalcemia of Malignancy (Pseudohyperparathyroidism)

! Hypoparathyroidism

! Hypocalcemia Syndromes Associated with Parturition

! Hypercalcitoninism

! Hypocalcitoninism

SECONDARY HYPERPARATHYROIDISM
RENAL HYPERPARATHYROIDISM
Secondary hyperparathyroidism as a complication of chronic renal failure is a metabolic state characterized by an excessive,
but not autonomous, rate of PTH secretion. This disorder is encountered frequently in dogs and occurs occasionally in cats.
The secretion of hormone by the hyperplastic parathyroid glands usually remains responsive to fluctuations in blood calcium
levels. The primary etiologic mechanism in this disorder is longstanding, progressive renal disease resulting in severely
impaired function. Chronic renal insufficiency in older dogs results from interstitial nephritis (Fig. 59-32),
glomerulonephritis, nephrosclerosis, or amyloidosis. Chronic renal disease with periglomerular and interstitial fibrosis in
Norwegian elkhounds has been reported to be familial.(63) Several congenital anomalies such as cortical hypoplasia,(108)
polycystic kidneys, and bilateral hydronephrosis may result in renal insufficiency in younger dogs.

FIG. 59-32 Severe interstitial nephritis in a dog with secondary

hyperparathyroidism of renal origin. The renal cortex (C) is thin
and replaced by fibrous connective tissue (arrow). The scale
represents I cm.

When the renal disease progresses to the point at which there is significant reduction in glomerular filtration rate, phosphorus
is retained and progressive hyperphosphatemia develops (Fig. 59-33). Although the concentration of blood phosphorus has
no direct regulatory influence on the synthesis and secretion of PTH, it may, when elevated, contribute to parathyroid
stimulation by virtue of its ability to lower blood calcium levels. Parathyroid stimulation in patients with chronic renal
disease can be attributed directly to the hypocalcemia. Recent evidence suggests that impaired intestinal absorption of
calcium due to an acquired defect in vitamin D metabolism plays a significant role in the development of hypocalcemia in
chronic renal insufficiency and uremia. Chronic renal disease interferes with the production of 1,25-DiOH-CC by the kidney,
thereby diminishing intestinal calcium transport and resulting in development of hypocalcemia (Fig. 59-33).

All parathyroids are considerably enlarged (Fig. 59-34) as a result initially of hypertrophy of chief cells and subsequently of
hyperplasia, as compensatory mechanisms to increase hormonal synthesis and secretion in response to the hypocalcemic
stimulus. Although the parathyroids are not autonomous, the concentration of PTH in the peripheral blood in canine and
human patients with chronic renal failure may exceed that of primary hyperparathyroidism(130) PTH increases osteoclastic
resorption(205) and bone remodeling,(144,145,196) resulting in release of stored calcium from bone. The longstanding
increase in bone resorption that attempts to return serum calcium levels to normal eventually results in the metabolic bone
disease associated with chronic renal insufficiency. Progressive glomerular and tubular dysfunction with loss of target cells
interferes with an expression of the phosphaturic response by the increased circulating PTH in renal disease. Phosphate is
retained and the blood concentration continues to rise in spite of the secondary hyperparathyroidism (see Fig. 59-33).

FIG. 59-33 Alterations in levels of serum calcium and

phosphorus during the pathogenesis of secondary
hyperparathyroidism associated with progressive renal
failure.

FIG. 59-34 Enlargement of parathyroid glands (arrows) due to chief

cell hypertrophy and hyperplasia in a dog with chronic renal disease.
(T. thyroid gland)

Although skeletal involvement is generalized in hyperparathyroidism, it does not affect all parts uniformly. Lesions become
apparent earlier and reach a more advanced stage in certain areas, such as cancerous bone of the skull. In dogs with
longstanding renal disease, the increased osteoclastic resorption results in the formation of cystic (radiolucent areas) in bones
of the skull giving a "moth-eaten" appearance (Figs. 59-35 and 59-36), similar to that of primary hyperparathyroidism.
Resorption of alveolar socket bone and loss of lamina dura dentes occurs early and results in loose teeth, which may be
dislodged easily and interfere with mastication (Fig. 59-37). The nasal cavity may be impinged upon owing to partial collapse
of surrounding poorly mineralized bone and displacement of the medial nasal septum.

FIG. 59-35 Radiograph (postmortem) of skull bones of a dog with

severe secondary hyperparathyroidism associated with chronic renal
disease. There is diffuse demineralization with localized areas of
accentuated bone resorption.

FIG. 59-36 Transilluminated gross photograph of skull bones

(illustrated in Figure 59-35) of a dog with chronic renal disease.
The bones of the skull are extremely thin, thereby permitting
transmission of light, owing to the extensive PTH-stimulated bone
resorption.

FIG. 59-37 A radiograph (postmortem) of mandibular rami of a dog

with secondary hyperparathyroidism of renal origin. There is diffuse
demineralization of the rami with loss of lamina dura denies and
localized radiolucent areas (arrows) due to extensive resorption of
alveolar socket bone.

Cancerous bone of the maxilla (Fig. 59-38) and mandible also is a site of predilection in hyperparathyroidism. As a result of
the accelerated resorption, bone of the mandibles becomes softened and readily pliable ("rubber jaw disease"; Fig. 59-39),
and the jaws fail to close properly. This often results in drooling of saliva and protrusion of the tongue. The severely
demineralized mandibles are predisposed to fractures and displacement of teeth from alveolar sockets. Long bones of the
abaxial skeleton are affected less dramatically. Lameness, stiff gait, and the occurrence of fractures after relatively minor
trauma may result from increased bone resorption.
 FIG. 59-38 Radiograph (postmortem) of maxilla from a dog with
severe renal secondary hyperparathyroidism. There is diffuse
demineralization of cancerous bone and loss of lamina dura denies
(arrows).

FIG. 59-39 Renal secondary hyperparathyroidism in a dog with extreme

pliability of the maxilla and mandible (arrow) ("rubber jaw") due to
excessive bone resorption stimulated by parathyroid hormone. Photograph
taken after death.

The predominant clinical signs of vomiting, dehydration, polydipsia, depression, and an ammonia odor to the breath are
related to progressive renal insufficiency and uremia. A spectrum of skeletal lesions of secondary hyperparathyroidism may
be present, ranging from minor changes with early (or mild) renal disease to the severe fibrous osteodystrophy of advanced
renal failure. Histologic evaluation of the skeleton in dogs with chronic renal disease reveals that a high percentage have
generalized fibrous osteodystrophy.(114) The volume of affected bones is usually normal (isostotic fibrous osteodystrophy),
particularly in older dogs because of the slow onset of renal failure and lower metabolic activity of bones. Hyperostotic bone
lesions, such as facial swellings, may be seen in younger dogs(143) in whom deposition of osteoid by hyperplastic
osteoblasts (stimulated by high blood phosphorus levels) and repair by proliferation of fibrous connective tissue exceed the
rate of resorption, resulting in a greater than normal bone volume.

Serum should be analyzed for calcium, phosphorus, and alkaline phosphatase. Results of a single determination of these
parameters must be interpreted with an appreciation that considerable variation exists, depending upon the stage of the
disease, because of the body's compensatory mechanisms (see Fig. 59-33). The blood calcium level is variable but usually is
in the low normal range because of mobilization of skeletal reserves. Most cases of chronic renal failure either have a normal
or low serum calcium concentration with varying degrees of elevation in blood phosphorus values. However, 5% to 10% of
dogs with chronic renal failure have serum calcium values of 12 mg/dl or greater.(64,202)

Pathogenic mechanisms that have been suggested to explain the development of hypercalcemia in certain cases of chronic
renal failure include decreased excretion of calcium by the diseased kidney, decreased renal tubular degradation of PTH,
PTH-induced hypercitricemia with a consequent increase in complexed calcium, autonomous transformation or
overcompensation by the parathyroid gland, and an exaggerated response to vitamin D with increased intestinal calcium
absorption. In our experience, microscopic evaluation has failed to reveal evidence of autonomous or overcompensated
parathyroid glands in dogs with hypercalcemia associated with chronic renal disease.

A transient and mild hypercalcemia has been observed in chronic renal failure in dogs following a precipitous decline in the
blood phosphorus value through treatments with intestinal binding agents (e.g., aluminum hydroxide) and fluid therapy. This
may be a consequence of a reciprocal movement of calcium from the bone fluid to the extracellular fluid space in response to
the rapid lowering of circulating phosphorus levels. Persistent hypercalcemia has been reported in human patients during the
diuretic phase of acute renal failure associated with rhabdomyolysis and is thought to be caused by mobilization of calcium
from soft tissues, where it was initially deposited during oliguria. Dogs have been observed recovering from the oliguric
phase of acute primary renal failure who developed hypercalcemia during diuresis. The hypercalcemia resolved without
specific treatment.

Alkaline phosphatase activity may be elevated in animals with overt bone disease and renal hyperparathyroidism. Urinary
excretion of calcium and phosphorus is decreased in patients with chronic renal disease.

The aim of treatment of renal hyperparathyroidism ideally would be to interrupt the progression of kidney disease and restore
or replace renal function to a semblance of normal. Because of the stage at which the diagnosis is established in animals and
the progressive nature of the disease, treatment is directed realistically toward reducing the excretory load and providing
substances (such as sodium chloride or bicarbonate, and water) that the failing kidney is unable to conserve. A K/D
prescription diet with supplemental calcium (gluconate or lactate) and vitamin D may diminish the severity of
hyperparathyroidism and accompanying bone lesions. Recent evidence in human patients suggests that 1,25DiOH-CC or
lo^hydroxycholecalciferol has considerable potential in the therapy of impaired intestinal absorption of calcium,
hypocalcemia, and osteomalacia associated with chronic renal disease.

NUTRITIONAL HYPERPARATHYROIDISM
The increased secretion of PTH in this metabolic disorder is a compensatory mechanism directed against a disturbance in
mineral homeostasis induced by nutritional imbalances. The disease occurs commonly in dogs, cats (Fig. 59-40), certain
primates, and laboratory animals, as well as in many farm animals. Dietary mineral imbalances of etiologic importance in the
pathogenesis of nutritional secondary hyperparathyroidism are a low content of calcium; excessive phosphorus with normal
or low calcium; and inadequate amounts of cholecalciferol (vitamin D3) in New World nonhuman primates housed indoors
without exposure to sunlight. The significant end result is hypocalcemia, which results in parathyroid stimulation (Fig. 59-
41).

FIG. 59-40 Kitten with secondary hyperparathyroidism of

nutritional origin. The kitten was reluctant to move, owing to
bone pain, and there was lateral deviation of the paws.

FIG. 59-41 Alterations in levels of serum calcium and

phosphorus in the pathogenesis of secondary
hyperparathyroidism in carnivores fed unsupplemented meat
diets low in calcium and in New World nonhuman primates
confined indoors and fed diets lacking adequate vitamin D3.

A diet low in calcium fails to supply the daily requirement, even though a greater proportion of ingested calcium is absorbed
and hypocalcemia develops.(32,175) Ingestion of excessive phosphorus results in increased intestinal absorption and
elevation of blood phosphorus levels. Hyperphosphatemia does not stimulate the parathyroid gland directly but does so
indirectly by virtue of its ability to lower blood calcium levels (see Fig. 59-33). In response to the nutritionally induced
hypocalcemia, all parathyroid glands undergo cellular hypertrophy and hyperplasia (Figs. 59-42 and 59-43). The expanded
cytoplasmic area of hyperactive chief cells contains large mitochondria, prominent Golgi complexes, and lamellar arrays of
rough endoplasmic reticulum but few PTHcontaining secretory granules (Fig. 59-44),(32) Plasma membranes of adjacent
hyperactive chief cells are intricately interdigitated (Fig. 59-44) Since kidney function is normal, the increased levels of PTH
result in diminished renal tubular reabsorption of phosphate and increased reabsorption of calcium, returning blood levels
toward normal (see Fig. 59-41). In addition, osteoclastic bone resorption is accelerated, and release of calcium elevates blood
calcium levels to the low normal range. Continued ingestion of the unbalanced diet sustains the state of compensatory
hyperparathyroidism, leading to progressive development of the metabolic bone disease.

FIG. 59-42 Chief cells in parathyroid gland of a cat fed a balanced control
diet. Chief cells are smaller (especially the cytoplasmic area), more
loosely arranged, and perivascular spaces are more prominent (arrow)
than in cats fed a low-calcium diet (see Fig. 5943). (H&E, x 315)

The disease develops in young pups and kittens fed a predominantly meat diet. For example, beef heart or liver contains
minimal amounts of calcium (7-9 mg per 100 g) and has a markedly imbalanced calcium/phosphorus ratio ( 1:20 to 1: 50).
The feeding of a monotonous meat diet to dogs of any age results in secondary hyperparathyroidism with the development of
skeletal disease of varying severity. The low calcium content and unfavorable calcium/phosphorus ratio of nonsupplemented
all-meat diets are unable to fulfill the daily requirements for either growing pups (528 mg of calcium and 440 mg of
phosphorus/kg of body weight/day) or adult dogs (264 mg of calcium and 220 mg of phosphorus/kg of body weight/day).
The diet of kittens up to 6 months of age should supply 200 mg to 400 mg of calcium and approximately 200 ,ug of iodine
daily, and from 10,000 IU to 15,000 IU of vitamin A weekly.(175) The addition of iodine to allmeat diets prevents the
development of thyroid hyperplasia in cats but not the skeletal disease.

FIG. 59-43 Chief cell hypertrophy and hyperplasia in the parathyroid

gland of a cat with nutritional secondary hyperparathyroidism. The
hyperactive chief cells are enlarged, lightly eosinophilic, and closely
packed together, with narrow perivascular spaces (arrow). (H&E, x 315)

FIG. 59-44 Hyperactive chief cells in the parathyroid gland of an experimental cat fed a
low-calcium diet for 9 weeks. The plasma membranes of adjacent hyperactive chief
cells are intricately interdigitated (arrows). The cytoplasm of the chief cells contains
lamellar arrays of endoplasmic reticulum, prominent Golgi complexes (G) with
numerous prosecretory granules, filamentous mitochondria, and aggregations of
ribosomes. Mature secretory granules are infrequent (arrowhead) and situated near the
periphery of the chief cells in response to the dietinduced hypocalcemia. (original
magnification x 96003 (Capen CC, Rowland GN: Ultrastructural evaluation of the
parathyroid glands of young cats with experimental hyperparathyroidism. Z Zellforsch
Mikrosk Anat 90:495, 1968)

Kittens that are fed beef heart exclusively develop locomotor disturbances within 4 weeks. The predominant clinical signs are
a reluctance to move, posterior lameness, and an incoordinated gait. The kittens often assume a standing position with
characteristic deviation of the paws. The skeletal disease becomes progressively more severe after 5 to 14 weeks. The cortex
of long bones is greatly thinned owing to the increased resorption, and the medullary cavity is widened (Fig. 59-45). The
kittens become quiet and reluctant to play. They assume a sitting position or are in sternal recumbency with the hindlegs
abducted at the pelvis. Normal activities may result in the sudden onset of severe lameness due to incomplete or folding
fractures of one or more bones. In kittens that are fed beef heart, the high content of digestible protein (over 50% on a wet
basis) and fat promotes rapid growth. These animals appear well nourished and their coat maintains a good luster.

FIG. 59-45 Radiograph of a kitten with nutritional secondary

hyperparathyroidism illustrates generalized skeletal demineralization
with bilateral folding fractures of the femur (arrows), thin Vortices of
long bones, and a fracture of the pelvis near the acetabulum.

Nutritional secondary hyperparathyroidism has been reported frequently in Siamese and Burmese kittens, but skeletal lesions
can be induced readily in other breeds. The indulgence of fussy eating habits with undesirable diets by their owners, rather
than a genetic predisposition, probably accounts for the higher incidence of the disease in the Siamese and Burmese breeds.

Various terms have been used to describe this metabolic disorder in cats, including osteogenesis imperfecta, juvenile
osteoporosis, and paper-bone or Siamese cat disease. In general, kittens are more susceptible to this disorder and develop
more severe skeletal lesions than adult cats fed a similar diet. Adult cats fed a beef heart diet develop osteoporosis slowly
after a period of months in response to increased PTH secretion, whereas the skeletons of kittens develop severe generalized
osteitis fibrosa within a few weeks. The disease develops rapidly in kittens because the dietary imbalance is wide and their
skeletal metabolic rate is high. Resorption proceeds at a faster rate than repair by fibrous connective tissue proliferation and
results in a decreased bone volume (hypostotic fibrous osteodystrophy). Fractures of long bones are bridged by a poorly
mineralized fibrous callus in untreated animals. Vertebral fractures with compression of the spinal cord and paralysis are
common in kittens (Fig. 59-46) but infrequent in adult cats.

FIG. 59-46 Radiograph of lumbar

vertebrae of a kitten with
nutritional secondary
hyperparathyroidism. Note the loss
of trabecular bone, thinning of the
cortex, and cavitation of the
vertebral body (arrow).

Lameness is the initial functional disturbance in growing dogs and may vary from a slight limp to complete inability to walk.
The bones are painful on palpation, and folding fractures of long bones and vertebrae are not uncommon. Clinical signs
usually are related to resorption of jaw bones in adult dogs. PTH-stimulated resorption of alveolar socket bone results in loss
of lamina dura dented loosening and subsequent loss of teeth from their sockets, and recession of gingiva with partial root
exposure in advanced cases.

In order to establish a definite diagnosis the diet should be evaluated for calcium, phosphorus, and vitamin D content in
patients (particularly young and rapidly growing animals) with skeletal disease. In nutritional hyperparathyroidism, there is
radiographic evidence of generalized skeletal demineralization, loss of lamina dura dented subperiosteal cortical bone
resorption, bowing deformities, and multiple folding fractures of long bones (see Fig. 59-45) due to intense localized
osteoclast proliferation (Fig. 59-47). Laboratory parameters used to assess renal function should be within normal limits in
patients with nutritional hyperparathyroidism.

FIG. 59-47 Localized accentuation of osteoclastic activity (arrows) along

bone trabeculae in a cat with nutritional secondary hyperparathyroidism.

Analysis of the serum for calcium, phosphorus, and alkaline phosphatase should be undertaken with an appreciation that one
determination may be of limited diagnostic value. Since the body's compensatory mechanisms with this disease are complex
and operational when the animal is seen for the first time, serum calcium and phosphorus levels usually are in a low normal
range. Alkaline phosphatase activity often is elevated in animals with overt bone disease. The increased PTH secretion acts
on the normal kidneys to increase phosphate and decrease calcium excretion in the urine (see Fig. 59-41).

The aim of treatment of nutritional hyperparathyroidism is to decrease PTH secretion by correcting the dietary mineral
imbalance or deficiency. Kittens and pups with the disease should be fed a diet that fulfills their high demand for animal
protein and meets the daily requirements for calcium and phosphorus. Calcium gluconate, lactate, or carbonate, alone or in
combination, should be used as dietary supplements to achieve a 2:1 calcium/phosphorus ratio during the healing phase in
young animals with severe bone disease. Additional vitamin D usually is not necessary but may be indicated in severely
affected animals to increase intestinal absorption of calcium. Calcium gluconate should be given parenterally if the appetite is
depressed. The feeding of excessive amounts of calcium for prolonged periods should be avoided both therapeutically and
under normal conditions because it may retard growth and alter remodeling of bone in young dogs.

Affected animals should be confined for at least 3 weeks after initiation of the supplemental diet. The response to therapy is
rapid, and within a week the animals become more active and their attitude improves. Jumping or climbing must be
prevented because the skeleton is still susceptible to fractures. The restrictions need be less rigid after 3 weeks, but
confinement with limited movement is indicated until the skeleton returns to normal. Improvement of the skeleton during
dietary supplementation can be followed radiographically. Fracture calluses become radiodense and the overall mineral
density and cortical bone thickness increase progressively with treatment. The skeleton is usually healed after feeding the
supplemental diet (calcium/phosphorus ratio of 2:1) for 8 to 9 weeks. Subsequently, the diet should supply the total daily
requirement of calcium and phosphorus and be balanced at about 1.2:1.0. Even advanced cases respond favorably to dietary
supplementation. Good nursing care is essential to prevent complications such as decubital ulcers, constipation, and
additional fractures. Healed pelvic fractures may predispose to dystocia and obstipation. Hypoplasia of the pelvic lumen of
cats is not uncommon. These animals may develop megacolon secondary to the pelvic constriction.

FIG. 59-48 Alterations in levels of serum calcium and

phosphorus in response to an autonomous secretion of
parathyroid hormone in primary hyperparathyroidism.

PRIMARY PARAHYPERTHYROIDISM
In primary hyperparathyroidism PTH is produced in excess of normal by a functional lesion in the parathyroid gland. This
disease is encountered infrequently in older dogs (35,72,114,118,156,183) Primary hyperparathyroidism does not appear to
be a sequela of long-standing secondary hyperparathyroidism in animals. The normal control of PTH secretion by the
concentration of blood calcium is lost in primary hyperparathyroidism. Hormone secretion is autonomous, and the
parathyroid produces excessive hormone in spite of the increased blood calcium.4 PTH acts on cells of the renal tubules
initially to promote the excretion of phosphate and retention of calcium. A prolonged increased secretion of PTH results in
accelerated osteocytic and osteoclastic bone resorption (Fig. 59-48). Mineral is removed from the skeleton and replaced by
immature fibrous connective tissue. The bone lesion of fibrous osteodystrophy is generalized throughout the skeleton but is
accentuated in local areas such as in the cancerous bone of the skull.

The lesion in the parathyroid gland responsible for the excessive secretion of PTH in dogs usually is an adenoma composed
of active chief cells.(27) Adenomas are usually single, light brown-red, and usually located in the cervical region near, but
sharply demarcated from, the thyroid gland (Fig. 59-49); however, they may be present in the anterior mediastinum near the
base of the heart. Parathyroid neoplasms in the precardial mediastinum are derived from ectopic parathyroid anlage displaced
into the thorax with the expanding thymus during embryonic development. Histopathologic demonstration of a rim of normal
tissue and fibrous capsule in an enlarged parathyroid suggests a diagnosis of adenoma rather than hyperplasia (Fig. 59-50).
Thyroid C cells are markedly hyperplastic in response to the long-term hypercalcemia and appear as small white foci in the
thyroid gland (see Fig. 59-49). The hyperplastic C cells often displace the colloidcontaining follicles lined by follicular cells.

FIG. 59-49 Chief cell adenoma removed

surgically from a dog with primary
hyperparathyroidism. The parathyroid
adenoma (A) is sharply demarcated from the
adjacent thyroid by a thin fibrous capsule
(arrows). There are multiple foci of C-cell
hyperplasia (C) in the thyroid gland,
stimulated by the longterm hypercalcemia.

FIG. 59-50 Photomicrograph illustrates a thin fibrous capsule

(arrows) surrounding the chief cell adenoma (see Fig. 59-49)
that separates the tumor from the adjacent thyroid gland. Thin
strands of fibrous connective tissue (arrowheads) extend from
the capsule into the adenoma. (H&E, x 42)

Chief cell carcinomas are infrequent causes of primary hyperparathyroidism. Carcinomas tend to be larger than adenomas
and fixed to the underlying tissues owing to local infiltration of neoplastic chief cells.

In primary hyperparathyroidism functional disturbances often are observed as the result of weakening of bones by excessive
osteoclastic resorption. Lameness due to severe demineralization (Fig. 59-51) or fractures of long bones occurs after
relatively minor physical trauma. Compression fractures of weakened vertebral bodies may exert pressure on the spinal cord
and nerves, resulting in motor or sensory dysfunction.

FIG. 59-51 Diffuse demineralization of bones of the foreleg of a dog with

primary hyperparathyroidism. Cortical bone is thin and there are areas of
subpenosteal resorption (arrowheads).

Facial hyperostosis with partial obliteration of the nasal cavity by poorly mineralized woven bone and highly vascular fibrous
connective tissue and loss or loosening of teeth in alveolar sockets have been observed in dogs with primary
hyperparathyroidism (Fig. 59-52). This may result in an inability to close the mouth properly and the development of areas of
ulceration of the gingival mucosa. The abnormal accumulations of woven bone may partially occlude the nasal cavity (Fig.
59-53) and are composed of spicules of poorly mineralized osteoid, numerous capillaries, and immature connective tissue
fibers (Fig. 59-54). Active osteoblasts are embedded in the woven bone and are surrounded by abundant collagen fibers of
the osteoid, but there are only occasional initial foci of mineralization (Fig. 59-55). Numerous granules of amorphous
calcium phosphate are present within hyperactive osteoblasts in the woven bone (Fig. 59-56). The maxilla and rami of
mandibles often are coarsely thickened by the formation of excessive woven bone. Bones of the skull are thinned markedly
by the increased resorption and have a characteristic moth-eaten appearance radiographically.

FIG. 59-52 Primary hyperparathyroidism in a 12-year-old Scottish terrier

with severe hyperostotic fibrous osteodystrophy of the maxilla. The
maxilla and mandible both were pliable, and the teeth were embedded
loosely in fibrous connective tissue. The dog was unable to close its mouth
properly owing to the excessive proliferative reaction in the maxilla, and
there were focal areas of ulceration (arrows) of the gingival mucosa.

FIG. 59-53 Cross section of maxilla of a dog with primary

hyperparathyroidism illustrates encroachment on the nasal
cavity (arrowheads) by an extensive proliferation of poorly
mineralized woven bone (w) The scale represents 1 cm. (T.
teeth)

FIG. 59-54 Biopsy of hyperostotic fibrous osteodystrophy.

Photomicrograph illustrates poorly mineralized woven bone (see Fig.
59-53) in the maxilla of a dog with primary hyperparathyroidism.
Spicules of osteoid (W) are separated by the proliferation of
immature fibrous connective tissue and neocapillaries (arrows).

FIG. 59-55 Electron micrograph illustrates hyperactive osteoblasts

(OB) in woven bone (see Fig. 59-54) in the maxilla of a dog with
primary hyperparathyroidism. The osteoblasts have an extensive
network of endoplasmic reticulum (E) in the cytoplasm and are
surrounded by a fibrillar osteoid (o) matrix with scattered initial foci
of mineralization (arrows) (original magnification x 6000).

Primary hyperparathyroidism should be included in the differential diagnosis of older dogs with a clinical history of severe
generalized skeletal demineralization and normal renal function. Radiographic evaluation reveals areas of subperiosteal
cortical resorption, loss of lamina dura dentes, soft tissue mineralization, bone cysts, a generalized decrease in bone density,
and in advanced cases, Fractures. Hypercalcemia results in anorexia, vomiting, constipation, and generalized muscular
weakness due to decreased neuromuscular excitability.

FIG. 59-56 Electron micrograph of a hyperactive osteoblast in

woven bone of a dog with primary hyperparathyroidism. The
cytoplasm contains large mitochondria that have numerous
electron-dense granules of amorphous calcium-phosphate
(arrowheads) and distended cisternae of rough endoplasmic
reticulum (E). (original magnification x 22,000)

Quantitation of total blood calcium is the most important and practical laboratory test to aid in establishing the diagnosis of
primary hyperparathyroidism. Although other laboratory findings may be variable, hypercalcemia is a consistent finding and
results Tom accelerated release of calcium Tom bone. The blood calcium level of normal adult animals is near 10 mg/dl with
some variation depending upon the analytical method employed as well as the age and diet of the animal. Calcium values
consistently above 11.5 mg/dl should be considered to be in the hypercalcemic range. Dogs with primary
hyperparathyroidism usually have a greatly elevated blood calcium level (12-20 mg/dl or above). The blood phosphorus level
is low or in the low normal range (4 mg/dl or less) because of inhibition of renal tubular reabsorption of phosphorus by
excess PTH (see Fig. 59-48)

The urinary excretion of phosphorus and often of calcium is increased and may result in nephrocalcinosis and urolithiasis
(Fig. 59-57). Accelerated bone matrix catabolism is reflected by an increased excretion of hydroxyproline in the urine. The
activity of alkaline phosphatase may be elevated in the serum of animals with overt bone disease. The increased activity of
this enzyme is thought to result Tom a compensatory increase in osteoblasts along trabeculae as a response to mechanical
stress in bones weakened by excessive resorption. In humans the detection of elevated circulating levels of PTH by
radioimmunoassay has greatly facilitated the early diagnosis of hyperparathyroidism.

FIG. 59-57 Urinary bladder containing small calculi (arrow) in a dog

with hypercalcemia and primary hyperparathyroidism. The scale
represents 1 cm.

The objective of treatment of primary hyperparathyroidism is to eliminate the source of excessive PTH production. An
attempt should be made to identify all four parathyroid glands before excising any tissue. A correlation often exists in
humans between tumor size and the severity of hypercalcemia and bone disease. Single or multiple adenomas should be
removed in toto. In case all identifiable glands in the cervical region appear to be of normal or smaller size and a diagnosis
has been established with reasonable certainty, surgical exploration of the thorax near the base of the heart may be necessary
to localize the neoplasm.

Surgical removal of the functional parathyroid lesion results in a rapid decrease in circulating PTH levels, since the half-life
of PTH in plasma is approximately 20 minutes. It should be emphasized that plasma calcium levels in patients with overt
bone disease may decrease rapidly and be subnormal within 12 to 24 hours postsurgery, resulting in severe hypocalcemic
tetany. Hypocalcemia also has been observed in dogs with primary hyperparathyroidism following infarction of a functional
chief cell adenoma due to excessive palpation. Serum calcium levels should be monitored frequently following surgical
removal of a parathyroid neoplasm. Postoperative hypocalcemia (5 mg/dl and lower) can be the result of the following:
depressed secretory activity of chief cells due to long-term suppression by the chronic hypercalcemia or injury to the
remaining parathyroid tissue during surgery; abruptly decreased bone resorption as a result of lowered PTH levels; and
accelerated mineralization of osteoid matrix formed by the hyperplastic osteoblasts that was prevented previously from
undergoing mineralization by the elevated PTH levels. Infusions of calcium gluconate to maintain the serum calcium level
between 7.5 mg and 9.0 mg/dl plus feeding highcalcium diets and administering supplemental vitamin D therapy will correct
this serious postoperative complication. If hypercalcemia persists for a week or more after surgery or recurs after initial
improvement, the presence of a second adenoma or metastases from a carcinoma should be suspected.
Since many of the severe effects of hypercalcemia are accentuated by dehydration, disturbances in fluid balance should be
corrected in all instances. Replacement fluids such as isotonic lactated Ringer's or 0.9% sodium chloride solutions should be
administered intravenously.

Calciuresis may be enhanced by administering 0.9% sodium chloride intravenously, since the additional sodium presented to
the renal tubules diminishes calcium reabsorption. In cases of hypercalcemic crisis, intravenous administration of sodium
bicarbonate may be of value in temporarily reducing the toxic effects of elevated ionized calcium concentration. The
beneficial effect is related to diminution in the level of ionized calcium associated with alkalosis induced by sodium
bicarbonate.

Other causes of hypercalcemia that must be considered in differential diagnosis of primary hyperparathyroidism are vitamin
D intoxication, malignant neoplasms with osseous metastases, and PTH like activity ("pseudohyperparathyroidism") or other
boneresorbing substances produced by malignant neoplasms ("hypercalcemia of malignancy") of nonparathyroid origin
without metastases to bone.

The hypercalcemia of hypervitaminosis D may be of a magnitude similar to that in primary hyperparathyroidism but is
accompanied by varying degrees of hyperphosphatemia and normal serum alkaline phosphatase activity. Skeletal disease
usually is not present, since the increased concentrations of blood calcium and phosphorus are derived principally Tom
augmented intestinal absorption rather than bone resorption.(29,199)

Malignant neoplasms with osseous metastases may cause moderate hypercalcemia and hypercalciuria, but the alkaline
phosphatase activity and serum phosphorus are usually normal or slightly elevated. These changes are believed to be due to
release of calcium and phosphorus into the blood from areas of bone destruction at rates greater than can be cleared by the
kidney and intestine. Bone involvement is more sharply demarcated and localized to the area of metastases. Osteolysis
associated with tumor metastases has been shown to be the result not only of a physical disruption of bone by proliferating
neoplastic cells but also of the local production of humoral substances that stimulate bone resorption, such as prostaglandins
and osteoclast-activating factor. Multiple myeloma and Iymphosarcoma with widespread bone marrow infiltration have been
associated with hypercalcemia. Myeloma patients with hypercalcemia may have increased binding of calcium to an abnormal
quantity of globulin in addition to the increased amount of ionized calcium from bone dissolution.

Hypercalcemia also may be caused by multifocal osteolytic lesions associated with septic emboli, complete immobilization,
osteosarcoma, hypoadrenocorticism (Addison's-like disease),(137,193) hypocalcitoninism due to a destructive thyroid
disease, occasional cases of chronic renal disease, hemoconcentration, and hyperproteinemia. Metastatic tumors to bone are
not encountered commonly in dogs or cats with malignant neoplasms but may be associated with hypercalcemia at certain
stages of tumor growth. Primary bone tumors occasionally may be associated with hypercalcemia.(149) Bacterial or fungal
osteomyelitis and neonatal septicemia in puppies with septic emboli and Iysis of bone are sporadic causes of hypercalcemia.
Skeletal radiographs are indicated to document the sites and severity of multifocal bone lesions.

Hypercalcemia may be detected occasionally in dehydrated animals. The magnitude of elevation in blood usually is mild and
is attributed to fluid volume contraction that results in hyperproteinemia and an increased relative concentration of ionized
and nonionized calcium. The hypercalcemia rapidly resolves following fluid therapy. The majority of dehydrated animals do
not develop hypercalcemia.

Prolonged immobilization can lead to hypercalcemia as a consequence of continued bone resorption associated with
diminished bone accretion. Hypercalcemia of this type occurs infrequently in animals that cannot move around freely
because of extensive musculoskeletal or neurologic injury.

Hypercalcemia has been reported in experimentally adrenalectomized dogs and in some cases of naturally occurring
Addison's-like disease in dogs.(137,198) The magnitude of elevation in serum calcium values may exceed 26 mg/dl under
experimental conditions, whereas dogs with Addison's-like disease evaluated in our hospital have had blood calcium values
up to 15 mg/ dl. Experimental evidence suggests that the type of hypercalcemia associated with hypoadrenocorticism is
unusual in that the ionized calcium fraction remains normal while the nonionized calcium fraction increases. If the ionized
calcium does indeed remain normal, it follows that this type of hypercalcemia should not be deleterious to the animal. The
elevated calcium value rapidly returns to normal following treatment for hypoadrenocorticism.
HYPERCALCEMIA OF MALIGNANCY (PSEUDOHYPERPARATHYROIDISM)
Pseudohyperparathyroidism is a metabolic disorder in which PTHlike polypeptides or other bone-resorbing substances are
secreted in excessive amounts by malignant tumors of nonparathyroid origin. Criteria for the diagnosis of
pseudohyperparathyroidism include the following: (1) persistent hypercalcemia and hypophosphatemia; (2) absence of
radiographic or pathologic evidence of tumor metastases in bone; (3) atrophy of parathyroid glands and C-cell hyperplasia in
the thyroid gland; (4) remission of hypercalcemia when the tumor is destroyed or excised; (5) demonstration of
immunologically or biologically active PTH-like polypeptides or other boneresorbing substances in the tumor tissue; and (6)
exacerbation of hypercalcemia if the tumor recurs following therapy. Tumor cells in human beings and animals have been
shown to produce several humoral substances that induce calcium mobilization from bone, including PTHlike polypeptides,
(159,180) prostaglandins (PGE2),(70,176,190,197) osteoclast-activating factor, colony-stimulating activity, and transforming
growth factors.(135,136)

Hypercalcemia and hypophosphatemia develop in dogs and humans with various malignant neoplasms in the absence of bone
metastases and functional lesions in the parathyroid glands. Present evidence suggests that the hypercalcemia is the result of
ectopic secretion of bone-resorbing substances by anaplastic tumor cells,(184)most likely by the mechanism of genetic
derepression.

Rijnberk and co-workers(168,169) described a syndrome of pseudohyperparathyroidism in elderly female dogs associated
with perirectal adenocarcinomas. The dogs had persistent hypercalcemia and hypophosphatemia that returned to normal
following surgical excision of the neoplasm in the perirectal area. The hypercalcemia persisted following removal of the
parathyroid glands. Immunoreactive PTH levels were within the normal range for the dog but were inappropriately high for
the degree of hypercalcemia.

HYPERCALCEMIA ASSOCIATED WITH APOCRINE ADENOCARCINOMIA

Meuten and co-workers(128) reported detailed clinical, macroscopic, and histopathologic features of adenocarcinomas
arising from the apocrine gland of the anal sac in 36 dogs. This unique syndrome occurred in aged (mean 10 years),
predominantly female (92%) dogs and was characterized by persistent hypercalcemia (91%) and hypophosphatemia (71%).
Serum calcium values ranged from 11.4 mg to 24.0 mg/dl with a mean of 16.2 mg/dl. Tumor ablation resulted in a prompt
return to normocalcemia, but the hypercalcemia recurred with tumor regrowth, suggesting the neoplastic cells were
producing a humoral substance that increased calcium mobilization. All tumors had histopathologic features of malignancy
and 96% had metastasized to iliac and sublumbar Iymph nodes.

Functional disturbances in dogs with pseudohyperparathyroidism include generalized muscular weakness, anorexia,
vomiting, bradycardia, depression, polyuria, and polydipsia. These clinical signs are the result primarily of severe
hypercalcemia and complicate the problems associated with the malignant neoplasm.

FIG. 59-58 Hypercalcemia of malignancy. Perirectal region of a dog with

hypercalcemia and a small adenocarcinoma (arrow) derived from apocrine
glands of the anal sac. (A, anus; T. tail)

FIG. 59-59 Transverse section of perineum from a female dog with

hypercalcemia and an adenocarcinoma derived from apocrine
glands of the anal sac. Anal sacs (A) are present on both sides of
the rectum (R). A tumor nodule (arrows) 1 cm in diameter arising
in the wall of the left anal sac protrudes into its lumen. The scale
represents 1 cm. (Meuten DJ, Cooper BJ, Capen CC et al:
Hypercalcemia associated with an adenocarcinoma derived from
the apocrine glands of the anal sac. Vet Pathol 18:454, 1981)
Apocrine adenocarcinomas develop as a firm mass (81% unilateral) in the perirectal area, ventral-lateral to the anus, in close
association with the anal sac, but are not attached to the overlying skin (Figs. 59-58 and 59-59). This unique neoplasm that
develops from apocrine glands of the anal sac (Fig. 59-60) forms distinctive glandular acini with projections of apical
cytoplasm extending into a lumen (Fig. 59-61) and is histologically distinct from the more common perianal (circumanal)
gland tumor. The majority of neoplasms were histologically bimorphic with glandular and solid areas (Fig. 59-62). The solid
pattern of arrangement of neoplastic cells was characterized by sheets, microlobules, and packets separated by a thin
fibrovascular stroma. Pseudorosettes were common in solid areas adjacent to small blood vessels.

FIG. 59-60 Photomicrograph illustrates close anatomical relationship of

apocrine adenocarcinoma (T) to normal apocrine glands (G) in the wall of
the anal sac. The anal sac (A) is lined by stratified squamous epithelium.
(H&E, x 125) (Meuten DJ, Cooper BJ, Capen CC et al: Hypercalcemia
associated with an adenocarcinoma derived from the apocrine glands of the
anal sac. Vet Pathol 18:454, 1981)

FIG. 59-61 Photomicrograph of biopsy of an adenocarcinoma arising from

apocrine glands in the wall of the anal sac in a dog with
pseudohyperparathyroidism and persistent hypercalcemia. The glandular
acini are lined by single or multiple layers of columnar neoplastic cells
with characteristic apical projection of cytoplasm into the lumen
(arrowheads). The acini contain varying amounts of colloidlike material
and occasional inflammatory cells. (H&E, x 315) (Meuten DJ, Cooper BJ,
Capen CC et al: Hypercalcemia associated with an adenocarcinoma
derived from the apocrine glands of the anal sac. Vet Pathol 18:454, 1981)

FIG. 59-62 Photomicrograph of biopsy illustrates characteristic bimorphic

growth pattern in adenocarcinoma derived from apocrine glands of the anal
sac with adjacent solid areas (S) and acini (A) formed by neoplastic cells.
(H&E, x 125) (From Meuten DJ, Cooper BJ, Capen CC et al:
Hypercalcemia associated with an adenocarcinoma derived from the
apocrine glands of the anal sac. Vet Pathol 18:454, 1981)

FIG. 59-63 Electron micrograph of an adenocarcinoma derived from apocrine glands of

the anal sac in a dog with hypercalcemia. Tall columnar cells with microvilli (V) and a
prominent basement membrane (left) line the tubule. Adjacent tumor cells are joined by
tight junctions and desmosomes (D). A Golgi apparatus (G) is present in most cells.
Tumor cells contain scattered mitochondria and many small electron-dense granules
(arrows). (original magnification x 3900) (Meuten DJ, Capen CC, Kociba GJ et al:
Ultrastructural evaluation of an adenocarcinoma-derived from apocrine glands of the
anal sac associated with hypercalcemia in dogs. Am J Pathol 107: 167, 1982)

The tumor cells in adenocareinomas derived from apocrine glands of the anal sac ultrastructurally contained a well-developed
rough endoplasmic reticulum, clusters of free ribosomes, large mitochondria, and prominent Golgi apparatuses (Fig. 59-63).
Small, membrane-limited secretory granules often were present in the apical cytoplasm of neoplastic cells (Figs. 59-64 and
59-65). These granules were of similar size and electron density as PTH-containing storage granules in chief cells of normal
parathyroid glands; however, additional studies are required to determine if they contain hormonal activity.

FIG. 59-64 Electron micrograph illustrates the apical portion of a tumor cell
with microvilli containing a cluster of electrondense granules (G) that vary in
diameter from 200 nm to 400 nm, in a dog with hypercalcemia and an
adenocarcinoma derived from apocrine glands of the anal sac. Large,
electron-dense Iysosomal bodies (500 nm-1000 nm in diameter) are adjacent
to the nucleus. Clusters of microfilaments are present in the cytoplasm
(arrow). (original magnification x 8900) (Meuten DJ, Capen CC, Kociba GJ
et al: Ultrastructural evaluation of an adenocarcinoma derived from apocrine
glands of the anal sac associated with hypercalcemia in dogs. Am J Pathol
107:167, 1982)

FIG. 59-65 Small (200 nm-400 nm in diameter) electron-dense secretory-

like granules (arrows) in neoplastic cells with an electron-dense core,
closely applied limiting membrane, and narrow submembranous space in
a dog with hypercalcemia associated with an adenocarcinoma derived
from apocrine glands of the anal sac. (original magnification x 34,300)
(Meuten DJ, Capen CC, Kociba GJ et al: Ultrastructural evaluation of an
adenocarcinoma derived from apocrine glands of the anal sac associated
with hypercalcemia in dogs. Am J Pathol 107:167, 1982)

The parathyroid glands were small and difficult to locate or not visible macroscopically in 69% of dogs reported by Meuten
and coworkers.(128) Atrophic parathyroid glands in dogs with apocrine adenocarcinomas were characterized by narrow
cords of inactive chief cells with an abundant fibrous connective tissue stroma and widened perivascular spaces (Fig. 59-66).
The inactive chief cells had a markedly reduced cytoplasmic area, prominent hyperchromatic nuclei, and were closely packed
together (Fig. 59-67). These findings were interpreted to suggest that the apocrine adenocarcinomas were not producing a
substance that stimulated PTH secretion but rather the parathyroid glands were responding to the persistent hypercalcemia by
undergoing trophic atrophy. Thyroid parafollicular (C) cells often responded to the persistent elevation in blood calcium
levels by undergoing diffuse or nodular hyperplasia.(128)

FIG. 59-66 Inactive parathyroid gland of a dog with hypercalcemia

(15.8 mg/dl) and adenocarcinoma derived from apocrine glands of the
anal sac. Inactive chief cells have a reduced cytoplasmic area and
clumped nuclear chromatin. Narrow cords of chief cells are separated
by wide bands of collagen and prominent perivascular spaces (S).
(H&E, x 315) (Meuten DJ, Segre GV, Capen CC et al: Hypercalcemia
in dogs with adenocarcinoma derived from apocrine glands of the anal
sac: Biochemical and histomorphometnc investigations. Lab Invest
48:428, 1983)

Skeletal demineralization in dogs with pseudohyperparathyroidism was mild in comparison with other causes of
hypercalcemia and usually undetectable by conventional roentgenographic methods. Neoplastic cells from the perirectal
adenocarcinomas rarely metastasized to bone (1 of 36 dogs) and caused osteolysis.(123) Variable numbers of osteoclasts
have been detected on bone surfaces in dogs with marked hypercalcemia, possibly reflecting different states in the course of
the disease and phases of bone remodeling activity (Fig. 59-68). Osteolytic osteolysis was not detected microscopically, and
the cement lines were smooth and linear.(128)
 FIG. 59-67 Electron micrograph of inactive chief cells in parathyroid gland of a dog
with hypercalcemia (20.8 mg/dl), hypophosphatemia ( 1.8 mg/dl), and an
adenocarcinoma derived from apocrine glands of the anal sac. Inactive chief cells have
a reduced cytoplasmic area,straight plasma membranes with few uncomplicated
interdigitations, lipid bodies, and an electronlucent cytoplasm containing few secretory
organelles. (original magnification x 4500) (Meuten DJ, Segre GV, Capen CC et al:
Hypercalcemia in dogs with adenocarcinoma derived from apocrine glands of the anal
sac: Biochemical and histomorphometric investigations. Lab Invest 48:428, 1983)

FIG. 59-68 Biopsy of iliac crest of a dog with pseudohyperparathyroidism

associated with an apocrine gland adenocarcinoma of the anal sac
illustrates a portion of a bone surface with numerous osteoclasts
(arrowheads) closely associated with bone. (H&E, x 315)

Histomorphometric analysis indicated that dogs with apocrine adenocarcinomas and hypercalcemia had significantly
decreased trabecular bone volume as compared with age-matched control dogs (Table 59-1). Total resorptive surface
(Howship's lacunae with and without osteoclasts) was increased significantly, as were the number of osteoclasts per
millimeter of trabecular bone. By comparison, dogs with primary hyperparathyroidism also had significantly increased total
resorptive surface and numbers of osteoclasts (Table 59-1).(130)

TABLE 59-1 Histomorphometric

Evaluation of Lumbar Vertebrae From
Dogs With Hypercalcemia and
Adenocarcinomas Derived From
Apocrine Glands of the Anal Sac
Compared With Control Dogs and Dogs
With Primary Hyperparathyroidism

The mean concentration of iPTH in the plasma of dogs with hypercalcemia and apocrine adenocarcinomas was reported by
Meuten and co-workers(130) to be 168 + 40 pg/ml with a range of undetectable to 266 pg/ml (Fig. 59-69). The concentration
of iPTH in dogs with apocrine adenocarcinomas was not significantly different from the concentration in control dogs (322 +
33 pg/ml) or normocalcemic tumor controls (264 + 46 pg/ml) but was decreased significantly compared with that of dogs
with primary hyperparathyroidism. The concentration of iPTH in dogs with renal failure was markedly increased compared
with that of control dogs (Fig. 59-69). Plasma iPTH levels were undetectable in dogs with primary hypoparathyroidism but
increased in dogs with primary hyperparathyroidism (mean: 1540 pg/ml) (Fig. 59-69). Urea-hydrochloric acid extracts from
apocrine adenocarcinoma, tumors from normocalcemic control dogs, and lymph nodes from control dogs without tumors
were assayed for iPTH before and after precipitation with trichloroacetic acid. Immunoreactive PTH was not detected in
tissue extracts from any tumor or lymph node. The iPTH concentrations in extracts of parathyroid glands from adult dogs
were greater than 200.
 FIG. 59-69 Plasma iPTH concentrations in dogs with hypercalcemia associated with
adenocarcinomas derived from apocrine glands of the anal sac. Plasma iPTH levels
were decreased in dogs with apocrine carcinomas compared with those of control dogs.
Dogs with hypoparathyroidism (hypoPTH) had undetectable concentrations of iPTH,
whereas dogs with primary (hyperPTH) and secondary (renal hyperPTH)
hyperparathyroidism had increased concentrations of iPTH compared with control
dogs. Four of five dogs with chronic renal disease had iPTH values greater than 8300
pg/ml. The limit of detectability for the iPTH assay (112 pg/ml) is indicated by the
shaded area. Horizontal lines indicate the mean for the respective groups. (Meuten DJ,
Segre GV, Capen CC et al: Hypercalcemia in dogs with adenocarcinoma derived from
apocrine glands of the anal sac: Biochemical and histomorphometric investigations. Lab
Invest 48:428, 1983)

The mean serum concentration of 1,25-dihydroxyvitamin D (1,25DiOH-CC) in dogs with apocrine adenocarcinomas and
hypercalcemia was 23 pg/ml with a range of 7 pg to 58 pg/ml (Table 59-2). '3¡ Although these dogs had hypercalcemia and
normophosphatemia, the mean serum 1,25-DiOH-CC concentration was not significantly different from either group of
normocalcemic control dogs (Table 59-2). The concentration of 1,25DiOH-CC decreased twofold to eightfold following
excision of the apocrine adenocarcinomas (Fig. 59-70). The mean preoperative serum calcium level was 16.5 mg/dl, and the
mean preoperative serum 1,25-DiOH-CC concentration was 32 pg/ml, whereas postoperative values were 10 mg/dl and 6
pg/ml, respectively.

TABLE 59-2 Serum and Urine Data From Dogs With

Apocrine Gland Adenocarcinoma and Control Dogs

Dogs with carcinomas derived from apocrine glands of the anal sac have a significantly greater urine calcium excretion
(mean + SE = 0.35 + 0.11 mg/dl glomerular filtrate [GF]) than either control dogs (0.02 + 0.01 mg/ dl GF) or normocalcemic
tumor-control dogs (0.04 + 0.01 mg/dl GF) and have higher urine calcium levels than dogs with primary hyperparathyroidism
(0.12 + 0.06 mg/dl GF) (Fig. 59-71).(130) In addition, the results for fractional excretion of calcium (mean + SE) indicate
that the urinary excretion of calcium in dogs with apocrine carcinomas (2.1% + 0.7%) is significantly greater than that of
clinically normal dogs (0.2% + 0.05%).

Urinary cAMP per deciliter GF is increased significantly in dogs with carcinomas derived from apocrine glands of the anal
sac (mean: 337 + 0.44 nM) compared with that of clinically normal dogs (mean: 1.94 + 0.16 nM) but not compared with that
of tumor-control dogs (mean: 2.70 + 0.57 nM) (Fig. 59-71).(130) Urinary excretion of phosphorus and hydroxyproline has
been reported to be numerically higher in dogs with apocrine carcinomas than in control dogs, but the differences were not
significant (see Fig. 59-71).(130) Significant differences have not been demonstrated in the concentrations of serum albumin,
urea nitrogen, alkaline phosphatase, or phosphorus in dogs with apocrine adenocarcinomas (Table 59-2).
 FIG. 59 70 Changes in levels of serum calcium (CA), plasma iPTH, serum phosphorus
(P) and 1,25-(OH)D associated with tumor excision in dogs with apocrine
adenocarcinoma of the anal sac. Following tumor removal, calcium levels returned to
the normal range, iPTH concentrations increased twofold to 20fold, phosphorus
concentrations increased, and levels of 1,25(OH)D decreased twofold to eightfold.
Postoperative samples were obtained at 12 to 48 hours following tumor excision.
Shaded areas for P and CA represent laboratory reference values (mean +/- 2 SD for
100 normal adult dogs). Shaded areas for iPTH and 1,25-(OH)D are mean +/- 1 SD for
control dogs. The limits of detectability for iPTH (112 pg/ml) and 1,25(OH)D (4 pg/ml)
are indicated by broken lines. (Meuten DJ, Segre GV, Capen CC et al: Hypercalcemia
in dogs with adenocarcinoma derived from apocrine glands of the anal sac:
Biochemical and histomorphometric investigations. Lab Invest 48:428, 1983)

FIG. 59-71 Urinary excretion of hydroxyproline, cAMP, and calcium in dogs with
apocrine adenocarcinoma of the anal sac compared with that in normocalcemic controls
with and without tumors and in dogs with primary hyperparathyroidism. Levels of
calcium and cAMP excretion were significantly increased in dogs with apocrine
carcinomas compared with those in control dogs without tumors but not compared with
those of control dogs with tumors. cAMP excretion was significantly greater (P<0.05)
in hyperparathyroid dogs than in any other group. Hydroxyproline excretion in dogs
with apocrine carcinomas (19.6 +/- 3.9 ug/dl GF) was greater than in controls (9.3 +/-
1.4 (ug/dl GF) but this difference was not significant. Horizontal lines indicate mean for
the group. Significant differences (P<0.05) from control dogs are indicated by a and
from tumorcontrols by b. (Meuten DJ, Segre GV, Capen CC et al: Hypercalcemia in
dogs with adenocarcinoma derived from apocrine glands of anal sac: Biochemical and
histomorphometric investigations. Lab Invest 48:428, 1983)

Biopsy specimens from adenocarcinomas derived from apocrine glands of the anal sac usually have histologic evidence of
malignancy, and 96% metastasize to iliac or lumbar lymph nodes.(128) Invasion of tumor cells usually is present into
adjacent tissues and endothelial-lined vessels, forming emboli. Tumor cell emboli appear to be more common in lymphatic
vessels than in blood vessels (Fig. 59-72).

FIG. 59-72 Photomicrograph of biopsy illustrates tumor cell emboli (arrow)

of adenocarcinoma arising from apocrine glands of anal sac in Iymphatic.
(H&E, x 315) (Meuten DJ, Cooper BJ, Capen CC et al: Hypercalcemia
associated with an adenocarcinoma derived from the apocrine glands of the
anal sac. Vet Pathol 18:454, 1981)
Renal mineralization has been detected histologically in 90% of dogs with pseudohyperparathyroidism associated with
apocrine adenocarcinomas of the anal sac, particularly when the ion product for calcium and phosphorus was 50 or greater.
(128) Tubular mineralization was most pronounced near the corticomedullary junction (Fig. 59-73) but also was present in
cortical and deep medullary tubules, Bowman's capsule, and glomerular tuft. Mineralization was present less frequently in the
fundic mucosa of the stomach and endocardium.(128)

FIG. 59-73 Renal tubular mineralization (M) in a dog with hypercalcemia

associated with apocrine gland adenocarcinoma of the anal sac.
Desquamated epithelial cells (arrow) are present in the lumen of some
tubules. (H&E, x 315)

Dogs with adenocarcinomas derived from apocrine glands of the anal sac develop hypercalcemia secondary to the production
of humoral factor that appears to be distinct from iPTH or prostaglandin E2.(130) It increases bone resorption and the urinary
excretion of calcium and phosphorus. The inappropriate serum concentration of 1,25-DiOH-CC for the degree of
hypercalcemia in tumorbearing dogs and the rapid decrease following excision of the tumor suggests that the tumor may
secrete a substance or substances that alter the activity of the 1-alpha-hydroxylase in the kidney. The persistent
hypercalcemia causes secretory inactivity of the parathyroid glands and decreased production of iPTH. Surgical removal of
the tumor usually is followed by an increased secretion of iPTH that prevents the development of postoperative
hypocalcemia. The unknown humoral factor or factors secreted by this unique adenocarcinoma in dogs are different from
PTH in that they are not recognized by an immunoassay that detects canine iPTH, neither do they stimulate renal calcium
reabsorption. However, the substances do induce osteoclastic osteolysis and hyperphosphaturia, and they maintain normal
serum 1,25DiOH-CC levels in spite of the persistent hypercalcemia. Additional investigations into the pathogenesis of
hypercalcemia in dogs with apocrine adenocarcinomas may further the understanding of the mechanisms responsible for
cancer-associated hypercalcemia in animals and human beings.(130)

HYPERCALCEMIA ASSOCIATED WITH LYMPHOSARCOMA

Lymphosarcoma is the most common neoplasm associated with hypercalcemia in dogs and cats. (152, 213) Estimates of the
prevalence of hypercalcemia in dogs with Iymphoma vary from 10% to 40%. Peripheral lymph node enlargement may or
may not be detected, but there usually is evidence of anterior mediastinal or visceral involvement. It is not completely
resolved whether the hypercalcemia develops from the production of humoral substances by neoplastic cells (e.g., PTH-like
polypeptides, prostaglandins, osteoclast-activating factor) or from physical disruption of trabecular bone due to frequent
marrow involvement, or both.

Heath and co-workers(90) recently reported that serum iPTH levels were subnormal in hypercalcemic dogs with
lymphosarcoma and that plasma immunoreactive PGE2 levels did not differ from those of controls. Culture media from
normal Iymphoid tissue and control media had no effect on release of 45Ca from prelabeled fetal mouse forelimb bones;
however, media from tumor tissue increased 45Ca release. These findings suggest that the local production of bone-resorbing
factors (e.g., osteoclastactivating factor) is important in stimulating calcium release from bone in certain dogs with
Iymphosarcoma and hypercalcemia.

FIG. 59-74 Photomicrograph of lumbar vertebra of a dog with

hypercalcemia and Iymphosarcoma Several large osteoclasts
(arrowheads) are present in lacunae along a thin bone trabecula.
Hyperplastic osteoblasts (arrows) and prominent osteoid seams are
present adjacent to the resorptive surfaces. The marrow contains
neoplastic Iymphoid cells (N). (von Kossa-tetrachrome, x 700) (Meuten
DJ, Kociba GJ, Capen CC et al Hypercalcemia in dogs with
Iymphosarcoma Biochemical, ultrastructural and histomorphometric
investigations. Lab Invest 49:553, 1983)
 TABLE 59-3 Histomorphometric
Evaluation of Lumbar Vertebrae from
Dogs With Lymphosarcoma
(Hypercalcemic and Normocalcemic)
Compared With Control Dogs

In a recent study dogs with Iymphosarcoma and hypercalcemia were reported to have decreased trabecular bone volume and
increased osteoclastic osteolysis compared with control dogs and dogs with normocalcemia and Iymphosarcoma (Table 59-3)
(129) Only dogs with neoplastic cells in bone marrow had increased osteoclastic bone resorption. Dogs with hypercalcemic
Iymphosarcoma often had osteoclasts on trabecular bone surfaces opposite a surface lined by osteoid and large columnar
osteoblasts (Figs. 59-74 and 59-75). Bone surfaces in normocalcemic control dogs were smooth and lined by flattened
osteoblasts but only rarely by osteoclasts (Fig. 59-76). Dogs with Iymphosarcoma that were normocalcemic did not have
increased bone resorption. Hypercalcemic dogs with Iymphosarcoma had decreased concentrations of plasma iPTH and
serum 1,25-DiOH-CC compared with normocalcemic dogs with Iymphosarcoma and control dogs (Fig. 59-77). The plasma
concentration of 13,14-dihydro-15-keto- prostaglandin E2 (PGE2 M) was elevated (approximately two-fold) significantly in
hypercalcemic dogs with Iymphosarcoma compared to controls (Table 59-4). Immunoreactive PTH was not detected in
lymphosarcoma tissue.(129)

FIG. 59-75 Photomicrograph of a large osteoclast in a Howship's lacuna

on a bone trabecula. The ruffled border (arrow) of the osteoclast is in
intimate contact with the underlying bone mineral. (von Kossa-
tetrachrome, x 500)

FIG. 59-76 Photomicrograph of lumbar vertebra of a control dog with a

large trabeculum of bone that has smooth surfaces, no osteoclasts, and
flattened osteoblasts (arrow). (von Kossa-tetrachrome, x 700) (Meuten
DJ, Kociba GJ, Capen CC et al Hypercalcemia in dogs with
Iymphosarcoma: Biochemical ultrastructural and histomorphometric
investigations. Lab Invest 49:553, 1983)

TABLE 59-4 Serum and Urine Data From

Dogs With Lymphosarcoma and Control Dogs

Urine excretion of calcium, phosphorus, and hydroxyproline was increased in hypercalcemic dogs with lymphosarcoma (Fig.
59-78).(129) Light and electron microscopic examination of parathyroid glands revealed inactive or atrophic chief cells and
evidence of secretory inactivity in dogs with Iymphosarcoma and hypercalcemia. Ultrastructurally, lymphosarcomas were
composed of tumor cells with large nuclei and a paucity of cytoplasmic organelles. Lymphosarcoma in dogs with
hypercalcemia appeared to produce a bone-resorbing substance that was immunologically distinct from iPTH and 1,25-
DiOH-CC. This factor induced the resorption of bone and the mobilization of calcium only when the bone marrow was
infiltrated by tumor cells.
 FIG. 59-77 Dogs with Iymphosarcoma and hypercalcemia (LSA H-Ca) had lower
concentrations of plasma iPTH and serum 1,25-(OH)2D than normocalcemic
Iymphosarcoma dogs (LSA N-Ca), but the differences were not significant. Dogs with
hypoparathyroidism (HypoPTH) had undetectable concentrations of iPTH while dogs
with primary (hyperPTH) and secondary renal hyperparathyroidism(Renal Disease)had
increased concentrations of iPTH compared with control dogs. Four of six dogs with
chronic renal disease had plasma iPTH concentrations greater than 8300 pg/ml. The
limits of detectability for the iPTH assay (112 pg/ml) and the 1,25-COH)2D assay (4
pg/ml) are indicated by the shaded areas. Horizontal lines indicate the mean for the
respective groups. Different letters indicate significantly different means (P<0.05).
(Meuten DJ, Kociba GJ, Capen CC et al: Hypercalcemia in dogs with Iymphosarcoma:
Biochemical, ultrastructural and histomorphometric investigations. Lab Invest 49:553,
1983)

FIG. 59-78 Urinary excretion of calcium, cAMP, and hydroxyproline in five groups of
dogs. Urine calcium levels were significantly greater in hypercalcemic dogs with
Iymphosarcoma (LSA H-Ca:0.45 +/- 0.07 mg/dl GF) than in normocalcemic dogs with
Iymphosarcoma (LSA NCa:0.06 +/- 0.03 mg/dl GF), control dogs, and tumor-control
dogs (0.04 +/- 0.01 mg/dl GF). Hydroxyproline excretion was significantly increased in
dogs with Iymphosarcoma and hypercalcemia compared with control dogs and was
greater in hypercalcemic dogs with Iymphosarcoma than in normocalcemic dogs with
Iymphosarcoma. Urine cAMP was significantly greater (P<0.05) in hyperparathyroid
dogs than in control dogs and in dogs with Iymphosarcoma and hypercalcemia.
Horizontal lines indicate mean values. Different letters indicate significant differences
(P<0.05). (Meuten DJ, Kociba, GJ, Capen CC et al: Hypercalcemia in dogs with
Iymphosarcoma: Biochemical, ultrastructural and histomorphometric investigations.
Lab Invest 49:553, 1983)

HYPOPARATHYROIDISM
Hypoparathyroidism is a metabolic disorder in which either subnormal amounts of PTH are secreted by pathologic
parathyroid glands or the hormone secreted is unable to interact normally with target cells. Hypoparathyroidism has been
recognized in dogs, particularly in smaller breeds such as schnauzers and terriers.(23,113,131,178) A variety of pathogenic
mechanisms can result in an inadequate secretion of PTH. The parathyroid glands may be damaged or inadvertently removed
during the course of thyroid surgery. If the parathyroid glands or their vascular supply have been damaged, there often is
regeneration of adequate functional parenchyma and subsequent disappearance of clinical signs.

Idiopathic hypoparathyroidism in adult dogs usually is associated with diffuse Iymphocytic parathyroiditis resulting in
extensive degeneration of chief cells and replacement by fibrous connective tissue. In the early stages of Iymphocytic
parathyroiditis, there is infiltration of the gland with Iymphocytes and plasma cells and nodular regenerative hyperplasia of
remaining chief cells (Fig. 59-79). Later, the parathyroid gland is replaced completely by Iymphocytes, fibroblasts, and
neocapillaries with only an occasional viable chief cell. The Iymphocytic parathyroiditis may develop by means of an
immune-mediated mechanism, since a similar destruction of secretory parenchyma and Iymphocytic infiltration has been
produced experimentally in dogs by repeated injections of parathyroid tissue emulsions. (120)

FIG. 59-79 Photomicrograph of biopsy of external parathyroid gland

of a dog with Iymphocytic parathyroiditis that resulted in
hypoparathyroidism and hypocalcemic tetany. There is destruction of
chief cells (C), extensive infiltration with Iymphocytes (L) and
plasma cells, and nodular hyperplasia of remaining viable chief cells.
(T. thyroid gland, A, arterial branch to external parathyroid gland.)
(H&E, x 42)

Other possible causes of hypoparathyroidism include invasion and destruction of parathyroids by primary or metastatic
neoplasms in the anterior cervical area and trophic atrophy of parathyroids associated with long-term hypercalcemia. The
presence of numerous distemper virus particles in chief cells of the parathyroid gland may contribute to the low blood
calcium levels in certain dogs with this disease.(201) Agenesis of both pairs of parathyroids is a rare cause of congenital
hypoparathyroidism in pups. Certain cases of idiopathic hypoparathyroidism with histologically normal parathyroids in both
animals and humans may be due to a lack of the specific enzyme in chief cells that converts the proPTH molecule to the
biologically active PTH secreted by the gland (Fig. 59-80).

FIG. 59-80 Biosynthesis of parathyroid hormone (PTH) in chief

cells as part of a larger biosynthetic precursor molecule.
Proparathyroid hormone (PRO-PTH) is converted
enzymatically to PTH (1-84) before storage. The PTH is
converted to N-terminal (biologically active) and C-terminal
(biologically inactive) fragments by cells in the periphery.

Pseudohypoparathyroidism is a variant of the syndrome of hypoparathyroidism that has been reported in humans in which
target cells in kidney and bone are unable to respond to the secretion of normal amounts of PTH (13,55,58) This is due to a
lack of the nucleotide regulatory (N-) protein that couples the hormonereceptor complex to the catalytic subunit of adenylate
cyclase in the plasma membrane, resulting in an inability to form cAMP in target cells (see Fig. 59-l7),(58) Severe
hypocalcemia develops in patients with pseudohypoparathyroidism even though parathyroid glands are hyperplastic(170) and
iPTH levels are elevated.(13)

The functional disturbances and clinical manifestations of hypoparathyroidism are primarily the result of increased
neuromuscular excitability and tetany. Bone resorption is decreased because of the lack of PTH, and blood calcium levels
diminish progressively (4-6 mg/dl) (Fig. 59-81). Affected dogs are restless, nervous, and ataxic with weakness and
intermittent tremors of individual muscle groups that progress to generalized tetany and convulsive seizures. Concurrently,
blood phosphorus levels are substantially elevated owing to increased renal tubular reabsorption.

FIG. 59-81 Alterations in serum calcium and phosphorus in

response to an inadequate secretion of parathyroid hormone.
There is a progressive increase in serum phosphorus and a
marked decline in serum calcium to levels that result in
increased neuromuscular excitability and tetany.

Tetany should be stopped initially by returning blood calcium levels to near normal through the intravenous administration of
organic calcium solutions. Long-term maintenance of blood calcium levels in the absence of normal PTH secretion should be
attempted by feeding diets that are high in calcium and low in phosphorus and that are supplemented with calcium (gluconate
or lactate) and vitamin D3.
Large doses of vitamin D3 (25,000 50,000 or more units/day depending upon the size of the dog) may be required initially to
elevate the blood calcium level in hypoparathyroid patients, since the lack of PTH diminishes the rate of formation of the
biologically active vitamin D metabolite by the la-hydroxylase system in the kidney (see Fig. 59-28). In order to prevent the
development of hypercalcemia and extensive soft tissue mineralization, the clinician should carefully adjust the dosage of
vitamin D by frequently determining the serum calcium levels. After adjusting the dose of vitamin D, a 4-to 5-day interval
should precede the next blood calcium determination in order to fully assess the effects of the change in vitamin D.

Once the blood calcium level has been returned to the normal range, substantially lower doses of vitamin D may be required
for longterm maintenance of blood electrolyte levels. In some dogs only dietary calcium supplementation is required for
long-term stabilization of the blood calcium level.(179)

Replacement therapy with either parathyroid extract or PTH derived from heterologous species (such as bovine) is expensive
and ineffective on a long-term basis because of the development of antibodies. Synthetic PTH, especially the biologically
active amino terminal (1-34) end of the molecule, and the active metabolite of vitamin D 1,25-DiOH-CC may be useful in the
treatment of hypoparathyroidism of animals in the near future as has been reported in human patients.(85,95,147)

HYPOCALCEMIC SYNDROMES ASSOCIATED WITH PARTURITION

Considerably less is known about the pathogenesis of hypocalcemic syndromes in the dog and cat than is known about their
development in the cow.(119,174) Puerperal tetany is encountered most frequently in the small, hyperexcitable breeds of
dogs and occasionally in the cat.(56) The clinical course is rapid and the bitch may proceed from premonitory signs of
restlessness, panting, and nervousness to ataxia, trembling, muscular tetany, and convulsive seizures in 8 to 12 hours.
(106,166) Hyperthermia frequently is associated with the increased muscular activity, and elevations of body temperature to
107¡F are not uncommon.

There is little evidence to suggest that puerperal tetany (eclampsia) in heavily lactating bitches is the result of an interference
in PTH secretion. Severe hypocalcemia and often hypophosphatemia develop near the time of peak lactation (approximately
1-3 weeks postpartum), probably as the result of an imbalance between the rates of inflow and outflow from the extracellular
calcium pool (Fig. 59-82). It is well known that feeding high-calcium diets to dairy cows in the prepartum period has a
provocative effect on the development of hypocalcemic disorders following parturition because of diminished responsiveness
of PTH-mediated bone resorption.(14,15) The reduced availability of calcium from skeletal sources leads to an excessive
reliance on intestinal calcium absorption.

FIG. 59-82 Relationship of inflow of calcium into the

extracellular fluid calcium pool (from bone resorption and
gastrointestinal absorption) and outflow of calcium into
milk, urine, feces and bone. An imbalance between the
rates of inflow and outflow from the extracellular fluid
calcium pool due to the increased loss in milk appears to
be an important factor in the pathogenesis of puerperal
tetany in the female dog.

Functional disturbances associated with hypocalcemia in the bitch are the result primarily of neuromuscular tetany (Fig. 59-
83), in contrast with those in the cow in which the principal clinical sign is paresis. Excitation-secretion coupling is
maintained at the neuromuscular junction in the bitch with hypocalcemia. Tetany occurs as a result of spontaneous repetitive
firing of motor nerve fibers. As a result of the loss of stabilizing membrane-bound calcium, nerve membranes become more
permeable to ions and require a stimulus of lesser magnitude to depolarize.

Clinical diagnosis is based on history, clinical signs, and response to therapy in most cases. If laboratory facilities are readily
available, demonstration of hypocalcemia with serum calcium levels less than 7 mg/dl confirms the clinical diagnosis. The
serum phosphorus level often is lowered to a comparable degree. The blood glucose determination is in the low normal range
or decreased as a result of the intense muscular activity associated with tetany.

The slow intravenous administration of an organic calcium solution such as calcium gluconate should result in rapid clinical
improvement and cessation of tetanic spasms within 15 minutes. For most bitches weighing between 5 kg and 10 kg, 5 ml to
10 ml of 10% calcium gluconate will provide sufficient calcium. Intravenous administration should proceed slowly to avoid
inducing ventricular fibrillation and cardiac arrest.

FIG. 59-83 Puerperal tetany with increased

neuromuscular excitability in a female dog with
hypocalcemia due to maintenance of excitation-secretion
coupling at the motor end-plate.

Puppies should be removed from the bitch for 24 hours to reduce the lactational drain of calcium. During this period the
puppies should be fed a milk substitute or other appropriate diet. If the puppies are mature enough it is advisable to wean
them; otherwise, they should be returned to the bitch after the 24-hour period. Although some clinicians advocate the use of
corticosteroids in addition to calcium and vitamin D to prevent relapses after the original therapy, there is no logical basis for
use of these drugs in such treatment regimens. Since corticosteroids may lower serum calcium levels by interfering with
intestinal calcium transport, their real value in the treatment of eclampsia is questionable.

During gestation a good-quality, balanced diet with a calcium:phosphorus ratio of 1:1 or less that provides the required (but
not excessive) amounts of calcium may result in a more responsive calcium homeostatic mechanism to meet the markedly
increased demands of lactation.

Calcium homeostasis in animals fed balanced or relatively lowcalcium diets during gestation appears to be under better
control by PTH secretion with the approach of parturition and initiation of the lactational drain (Fig. 59-84). The higher
levels of PTH secreted during the prepartal period by an expanded population of actively synthesizing chief cells results in a
larger pool of active boneresorbing cells to fulfill the increased needs for calcium mobilization at the critical time near
parturition and initiation of lactation.(209) These animals appear to be less susceptible to the influence of decreased calcium
absorption and flow into the extracellular pool, which can occur in the immediate postpartum period and during early
lactation.

FIG. 59-84 Calcium homeostasis in animals fed a low calcium prepartal diet. Bone
resorption and intestinal absorption both contribute substantially to the inflow of
calcium to the pool in extracellular fluids under these conditions. If gastrointestinal
absorption of calcium is interrupted near parturition and initiation of lactation, animals
fed a low calcium diet are more likely to have an adequate pool of active bone-
resorbing cells capable of responding rapidly to an increased secretion of parathyroid
hormone and thus maintain an approximate balance between calcium inflow and
outflow.

Calcium homeostasis in animals fed a high-calcium diet during gestation appears to be maintained principally by intestinal
calcium absorption (Fig.59-85). This greater reliance on intestinal absorption rather than on PTH stimulated bone resorption
probably is a significant factor in the more frequent development of hypocalcemia near parturition in animals fed high-
calcium diets prepartum. (14,15)
 FIG. 59-85 Calcium homeostasis in animals fed a high calcium prepartal diet is
dependent primarily upon intestinal calcium absorption. The rate of bone resorption is
low and parathyroid glands are inactive. An interference in gastrointestinal absorption
of calcium at parturition or early lactation will interrupt the major inflow into the
extracellular fluid calcium pool. Outflow of calcium with the onset of lactation exceeds
the rate of inflow into the calcium pool and animals may develop progressive
hypocalcemia.

HYPERCALCITONINISM
Clinical syndromes associated with abnormalities in the secretion of CT are recognized much less frequently than disorders
of PTH in both animals and humans. A hypersecretion of CT has been reported in humans,(89,181) bulls,(16,26,28) and
laboratory rats(22,47) with medullary (ultimobranchial) thyroid neoplasms derived from C cells. In humans the syndrome
often is familial with involvement of many persons in a kindred.

A medullary thyroid carcinoma that contained CT was reported by Leav and co-workers(117) in a dog with a firm mass in
the anterior cervical region and chronic watery diarrhea. CT activity was localized to the cytoplasm of tumor cells by
immunoenzymatic techniques. Medullary (C-cell) carcinomas may secrete humoral substances other than CT, such as
prostaglandins, serotonin, and bradykinin, that result in a wide spectrum of clinical manifestations.(126)

The incidence of C-cell tumors of the thyroid in dogs is uncertain, but it appears to be greater than previously expected.
Zarrin(212) reported that 7 of 200 thyroid gland tumors in dogs were derived from C cells. They often are firm on palpation
owing to the presence of large amounts of amyloid in the stroma (Fig. 59-86). Thyroid neoplasms of C-cell origin can be
readily differentiated ultrastructurally by the presence of numerous membrane-limited secretory granules in the cytoplasm
(Fig. 59-87).(26) Small granules of this type are not present in thyroid tumors derived from follicular cells. C-cell tumors in
both humans and animals may be associated with the simultaneous occurrence of pheochromocytoma in the adrenal medulla
and neoplasms in other endocrine organs. (181,208)

FIG. 59-86 Calcitonin-secreting C-cell tumor in thyroid gland of a

dog. The large accumulations of amyloid (A) in the interstitium give
this type of thyroid tumor a characteristically firm consistency. (H&
E, x 315)

FIG. 59-87 Electron micrograph of biopsy of a calcitonin-secreting

neoplasm derived from C cells in the thyroid of a dog. The
cytoplasm of neoplastic C cells contains prominent arrays of rough
endoplasmic reticulum (E), a large Golgi apparatus ( associated with
prosecretory granules, mitochondria, and characteristic
membranelimited secretory granules (s) (N. nucleus of tumor cell)

Serum calcium and phosphorus levels in adults with a chronic excessive secretion of CT either remain in the low normal
range owing to the relatively slow turnover rate of bone and compensatory increase in PTH secretion or are significantly
decreased below normal. Osteosclerotic changes have been reported in animals with this syndrome, but the relationship of
long-term excessive CT secretion to the pathogenesis of the skeletal lesions and their occurrence in other animal species is
uncertain. Histomorphometric analysis of iliac crest biopsies from human patients with hypercalcitoninemia revealed normal
trabecular bone volume but significant increase in fractional formation and labeled surfaces.(57) The bone formation rate at
tissue level was high normal.

HYPOCALCITONISM
Specific disease syndromes resulting from a lack of CT secretion have not been recognized in either humans or animals.
However, experimentally thyroidectomized animals are less able than normal animals to handle a highcalcium meal and may
develop postprandial hypercalcemia (Fig. 59-88). (187)

FIG. 59-88 Hyperealremic response to an oral calcium load in a

thyroidectomized animal without an endogenous source of calcitonin
compared with that of controls with an intact thyroid gland. (Barlet JP
Calcium homeostasis in the normal and thyroidectomized bovine
Horm Metab Res 4:300, 1972)

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