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Original Article

Modes of Presentation of Primary Hyperparathyroidism in

Al Hawari General Hospital, Benghazi‑Libya
Muftah S. Elsaeiti, Fadia S. Akhreim1, Khaled D. Alsaeiti2
Department of Endocrine and Internal Medicine, Faculty of Medicine, 1Faculty of Medicine, Benghazi University, 2Department of Medicine, Jamhoryia Hospital,
Benghazi, Libya

Abstract
Background: Primary hyperparathyroidism  (PHPT) is an endocrine disorder with variable clinical expression, frequently presenting as
asymptomatic hypercalcemia in western countries but still predominantly as symptomatic disease in developing countries. The objective of this
retrospective study was to describe the modes of presentation of this disease in Benghazi. Patients and Methods: Records of nineteen patients
diagnosed with PHPT at metabolic bone disease clinic of Al Hawari general hospital, Benghazi, Libya, during 2005–2012 were reviewed.
Results: Mean age at diagnosis was 41.7 ± 11.5 (range 20–70 years). There were 17 females and 2 males with a ratio of 8.5:1. Eighteen
patients (94.7%) were symptomatic. Skeletal manifestations were the major mode of presentation in seventeen patients (89.4%) followed by
renal stone in one patient (5.3%). All symptomatic patients had a single adenoma, nine of them (47.4%) had right inferior adenomas, and nine
had left inferior ones (47.7%), and no adenoma can be detected in asymptomatic patient (5.3%). More than half of the patients had normal serum
calcium levels (52.6%) at the time of diagnosis and (47.3%) had persistent hypercalcemia with a mean serum calcium level (10.7 ± 1.02 mg/dL),
all patients had high serum intact parathyroid hormone with a mean value of (696.3 ± 379.5 pg/mL), and high serum alkaline phosphatase
with a mean level of (901.9 ± 520.8U/L) except one patient who had low level of 20U/L. Vitamin D was measured only in six patients, five
of them were a deficit, and one asymptomatic patient had normal level. All our patient’s parathyroid adenomas were localized by Ultrasound.
Seventeen patients had successful surgery, one patient had a recurrence, and one asymptomatic patient was managed medically according to
the Third International Workshop guidelines. Conclusions: PHPT in Libya continues to be a severe, symptomatic disorder with skeletal, and
renal manifestations at a much younger age.

Keywords: Hypercalcemia, parathyroid adenoma, primary hyperparathyroidism

Introduction The various case studies worldwide show an annual incidence

Primary hyperparathyroidism (pHPT) is a common disorder
that arises from autonomous overproduction of parathyroid
hormone (PTH) by abnormal parathyroid glands. The disease
is characterized by the persistent elevation of total serum
calcium levels with corresponding elevated or inappropriately
normal (i.e., nonsuppressed) PTH levels. The diagnosis of is
biochemical. The clinical presentation is heterogeneous, and
the associated symptoms overlap with those of aging and
disease. Patients with symptomatic pHPT have overt signs
and symptoms; however, the definition of symptomatic disease
is still evolving. Patients with asymptomatic pHPT have no
disease‑specific symptoms.[1]
PHPT is the most common cause of hypercalcemia in an
outpatient.[2] It is the third most common endocrinopathy[3,4]
seen today after diabetes mellitus and thyroid disease.[4]
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of 20 cases per 100,000 people with an estimated prevalence
in the general population of 0.5% to 1% increasing with
age over  2% in both sexes.[5,6] It occurs 2–3  times more
frequently in women than in men and has a higher prevalence
in postmenopausal women.[7]
There are geographical differences in age distribution, in
western countries, PHPT mainly affects middle‑aged patients
with peak incidence in the sixth to seventh decades of life,
but in developing countries, it is more common in younger
age groups.[8]
Address for correspondence: Dr. Khaled Daifalla Alsaeiti,
Faculty of Medicine, Benghazi University, Benghazi, Libya.
E‑mail: Kads2930@yahoo.com
This is an open access article distributed under the terms of the Creative Commons
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DOI: How to cite this article: Elsaeiti MS, Akhreim FS, Alsaeiti KD. Modes of
10.4103/LJMS.LJMS_39_17 presentation of primary hyperparathyroidism in Al Hawari General Hospital,
Benghazi-Libya. Libyan J Med Sci 2018;2:22-5.

22 © 2018 Libyan Journal of Medical Sciences | Published by Wolters Kluwer - Medknow

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Elsaeiti, et al.: Primary hyperparathyroidism in Al hawari general hospital
Mortality and morbidity were increased for patients with mild
untreated PHPT, which is similar to more severe PHPT.[9]
The main cause is represented by a solitary parathyroid
adenoma (80%–85% of cases), the remaining 15%–20%
of cases are represented by conditions of diffuse glandular
hyperplasia and multiple adenomas. A  small percentage of
patients presents with typical familial forms of multiple
endocrine neoplasia (MEN 1 and MEN 2A) syndromes.[10]
The current study aims to describe the modes of clinical
presentation of PHPT among Libyan patients seen at metabolic
bone disease clinics in Benghazi.
Patients and Methods
Case series study in which the records of all diagnosed
PHPT cases from January 2005 to December 2012 based on
biochemical results were retrieved from the patient’s files at
metabolic bone disease clinic of Al Hawari General hospital,
Benghazi‑Libya, in which nineteen patients  (17  females
and 2 males) were diagnosed with PHPT. For each patient,
the following data was obtained: age, gender, clinical
presentation  (skeletal, renal, and others), laboratory data
included serum calcium  (normal range 8.6–10.2  mg/dl)
by Enzymatic Chlorometric  (Cobas C311, Switzerland),
serum intact parathyroid hormone  (iPTH)  (normal range
15–65 pg/ml) by Immunoassay (Cobas 6000, Germany), and
serum alkaline phosphatase  (normal range 40–129 U/L) by
Enzymatic Chlorometric  (Cobas C311, Switzerland), and
Vitamin D (25‑OHD3) was measured in six patients, normal
range (21–29 ng/ml) by Immunoassay (Cobas 6000, Germany).
Radiological localization methods were performed and the
site of adenoma was noted. Other radiological findings as
bone fracture and renal stones were also noted. Data about
management, operative findings (either single, multiple, or
ectopic adenoma) was also collected.
Statistical Package for Social Sciences (SPSS) software
(version 17, IBM, Armonk, NY, United States of America).
Frequency tables were analyzed using the Chi‑square test
and P values being used to assess the significance of the
correlation between the categorical variable. In all tests, the
values P < 0.05 were regarded statistically significant.
Results
An overwhelming majority (17/19; 89.5%) of the patients were
females giving a male:female ratio of 1:8.5. The mean age of
patients was 41.7 ± 11.5 with a range of 30–50 years and peak
incidence was in the third to fifth decades of life. The mean
duration of symptoms before diagnosis was (2–10) years.
The vast majority of patients (18/19, 94.7%) were symptomatic
skeletal manifestations  (proximal muscle weakness, bone
pain, bone cyst, and bone fracture) were the most common
presentation, seen in 17 (89.4%) patients (P < 0.05), two of
them were bedbound for 8 and 10 years, respectively, and were
diagnosed as osteomalacia at first. Renal manifestations were
Libyan Journal of Medical Sciences  ¦  Volume 2 ¦ Issue 1 ¦ January-March 2018
the least frequent complaint, only one patient (5.3%). None
of the patients presented with gastrointestinal disturbances
such as constipation, nausea or vomiting, and there were no
documented cases of neuropsychiatric manifestations.
All the patient’s adenoma was localized by neck ultrasound.
Single adenoma was involved in 18 cases (94.7%), and one
asymptomatic case had no adenoma. Among these 18 cases,
9  (47.7%) were right inferior in location, while 9  (47.4%)
were left inferior.
Nine patients (47.7%) had persistent hypercalcemia, 10 patients
(52.6%) had normal serum calcium at time of diagnosis. Mean
serum calcium level was (10.7  ±  1.02  mg/dl). All patients
had high iPTH with mean values of (696.3 ± 379.5 pg/mL).
The serum total ALP was elevated (>140  IU/L) in (94.7%)
of patients. The mean serum ALP was (901.9 ± 520.8 U/L).
Vitamin D (25‑OHD3) was measured in six patients and five
of them were deficient [Table 1].
Most of the patients displayed radiographic changes
suggestive of hyperparathyroid bone disease. DXA scan
was not available in all patients, it was reported only in
five patients, four of them had Osteopenia while the other
was asymptomatic with normal DXA scanning. Pathologic
fractures were evident in eight patients. Common sites
of fractures were pelvic and long bones. Renal disease
was present in one patient (5.3%). The pattern of kidney
involvement was nephrolithiasis.
Eighteen of patients managed surgically by traditional
4‑gland neck exploration with the identification of a single
adenoma and its removal with histopathological confirmation.
Successful parathyroidectomy led to cure in 17 patients, and
failed in one case, in which ectopic adenoma was suspected.
Postoperative hungry bone syndrome (HBS) was observed in
six patients. One asymptomatic patient was managed medically
according to the Third International Workshop guidelines for
the management of asymptomatic PHPT.
There was one patient died during the study because of
stone‑induced acute renal failure.
Discussion
We point that only nineteen patients were diagnosed between
2005 and 2012 at a reference public service. We believe that
this low figure could be related to a delayed pHPT diagnosis
and to a delayed pHPT diagnosis and to a still low recognition
of the disease.
As shown in the current study, female patients had higher
rates of pHPT as compared to males (89.5% and 10.5%,
respectively), and the mean age of patients was 41.7 ± 11.5 years,
with a peak incidence in the third to fifth decades, which is
two decades earlier than that in developed countries. This is
in alignment with previous reports from other developing
countries where the mean age reported was <50.[11,12,13,14] The
story is completely different in developed countries, in which
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Elsaeiti, et al.: Primary hyperparathyroidism in Al hawari general hospital

Table 1: Age and gender distribution of clinical characteristics of primary hyperparathyroidism patients
Total (%) Age
20‑30 (%) 31‑40 (%) 41‑50 (%) 51‑60 (%) 61‑70 (%)
Gender
Female 17 (89.5) 2 (11.8) 5 (29.4) 7 (41.2) 2 (11.8) 1 (5.8)
Male 2 (10.5) 1 (50) 0 0 1 (50) 0
Mode of presentation
Asymptomatic 1 (5.3) 0 0 1 (14.3) 0 0
Renal stone and bone fracture 1 (5.3) 0 1 (20) 0 0 0
Proximal muscle weakness, bone pain, and fracture 6 (31.5) 2 (66.6) 1 (20) 2 (28.6) 1 (33.3) 0
Jaw cyst 1 (5.3) 0 1 (20) 0 0 0
Proximal muscle weakness and bone pain 9 (47.3) 0 2 (40) 4 (57.1) 2 (66.6) 1 (100)
Proximal muscle weakness and bone fracture 1 (5.3) 1 (33.3) 0 0 0 0
Site of adenoma
Right inferior 9 (47.7) 2 (66.6) 4 (80) 1 (14.3) 1 (33.3) 1 (100)
Left inferior 9 (47.7) 1 (33.3) 1 (20) 5 (71.4) 2 (66.6) 0
No adenoma 1 (5.3) 0 0 1 (14.3) 0 0

hyperparathyroidism mainly affects middle‑aged patients with
a peak incidence in the sixth to seventh decades of life and a
female to male ratio of 2–3:1.[4,12,14,15]
One of the most important findings of the current study is that
eighteen patients  (94.7%) were symptomatic, seventeen of
them (89.4%) came with musculoskeletal manifestations, and
one (5.3%) with renal symptoms. This finding also comparable
with observations in most developing countries. In Brazil,
similar observation has been previously reported by Oliveria
et  al.[16] who found that 66% of patients were symptomatic.
Furthermore, similar observations have been reported in other
developing countries, such as Saudi Arabia and Iran.[12,14] It is not
clear why our patients present at a younger age, and why they are
symptomatic, some researchers explained the high percentage
of bone involvement with florid presentation in developing
countries by common coexistence of Vitamin D deficiency,
prolonged PHPT, and low calcium intake.[17] Low serum Vitamin
D levels in patients with PHPT were associated with worsening
laboratory, densitometric, and histomorphometric indices of
bone involvement and a high risk of fractures.[18] Likewise,
results of many studies have shown that coexisting Vitamin D
deficiency might result in advanced osteitis fibrosa cystica.[19]
developing countries could be attributed to the absence of
significant hypercalciuria, due to a low mean serum calcium
levels, most probably resulting from low dietary calcium
consumption and/or Vitamin D deficiency; supporting this is
the high prevalence of normocalcemic PHPT in many studies
from developing countries where its prevalence has been
reported from range between 3% and 50%.[24]
Surprisingly, in our study, there were 10 (52.6%) of nineteen
patients had serum calcium level within the normal range at the
time of diagnosis, and only nine patients (47.4%) had persistent
hypercalcemia, with a mean serum calcium level (10.7 ± 1.02).
this is may be explained in part by coexistence of Vitamin D
deficiency or by high prevalence of normocalcemic PHPT in
our country, further studies are needed with measurement of
serum Vitamin D and replacement if it is deficit to know the
cause of normal serum calcium in our patients. It has been
reported that patients may present with serum calcium levels
within normal ranges but normocalcemic hyperparathyroidism
in individuals with one and/or kidney involvement is a
rare finding in the west, in contrast to the prevalence of
normocalcemic hyperparathyroidism, reported to range from
3% to 50% in developing countries.[17]

Renal disease is considerably less frequent in our patients
which is consistent with studies from other developing
countries.[17,20]
In western countries, nephrolithiasis is still its most common
complication, but kidney stones  (KS) are less prevalent
than they used to be.[21] However, very few studies have
focused on the frequency of KS through imaging technology
in asymptomatic subjects. [22] Retrospective data give a
prevalence range of KS between 7 and 11% when abdominal
ultrasound is utilized.[23] By spiral computed tomography,
Starup‑Linde et al.[22] reported the prevalence of 15.2% and
10.1% for nephrolithiasis and nephrocalcinosis, respectively.
The low frequency of renal involvement in patients from
All our patients had single parathyroid adenoma which was
localized by neck ultrasound. One asymptomatic patient had
normal neck USS, and among 18  cases, nine patients had
right inferior adenomas, and nine patients had left inferior
parathyroid adenomas. There is only one study evaluated the
location of the parathyroid adenoma by Marzouki et al.[25] in
Monereal between 2001 and 2010. In this study, there were
121 patients with confirmed adenomas, 50 of them had left
inferior parathyroid adenomas, and 40  patients had right
inferior adenomas. This information may provide parathyroid
surgeon with a starting point when imaging fails to localize
the site of the adenoma, which allows for the possibility of
minimally invasive surgery, especially if used in conjunction
with intraoperative parathyroid hormone.[25]

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Elsaeiti, et al.: Primary hyperparathyroidism in Al hawari general hospital
In our study, Vitamin D measurement was not possible to all
cases. It was measured only in six patients, five of them were
deficient, and one was normal. Unfortunately, we could not
give full information about Vitamin D status in our patients.
Six out of eighteen operated cases developed HBS
postoperatively. Witteveen et  al. conducted a systemic
review of literatures reporting a “hungry bone syndrome” post
parathyroidectomy for PHPT, they found that the syndrome is
reported in 25%–90% of patients with radiological evidence of
hyperparathyroid bone disease versus only 0%–6% of patients
without skeletal involvement.[26]
There was one female died during the study after successful
parathyroidectomy, because of stone‑induced acute renal failure.
Mortality may still remain increased after PTX in overt PHPT,
albeit that risk gradually begins to improve approximately
5  years after surgery.[15] for patients undergoing PTX with
mild PHPT, improvements in BMD and dyslipidemia,[27] but
not mortality,[28] have been demonstrated.
Conclusions
Within the limits of this retrospective study, we found
that PHPT is a severe, symptomatic disease with serious
complications among Libyans. The advanced skeletal disease
is the most common pattern of presentation at a young age.
Furthermore, Vitamin D deficiency may be an unrecognized
public health problem among Libyan population. There is a
compelling need to take public health measures to improve
Vitamin D status in this part of Libya.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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