CALCIUM AND

PARATHYROID
DISORDERS
 CALCIUM
 TOTAL CALCIUM BODY STORES ??? 1 TO 1.3 KG

99% IN BONES > SOFT TISSUES > 0.1% IN ECF

3 COMPONENTS : CAN BE :
1] 50% IONISED – not attached to proteins
2] 40% PROTEIN BOUND
3] FORM COMPLEX WITH ANIONS [CITRATE,PHOSPHATE]
 NORMAL BLOOD CALCIUM LEVEL : 8.5 TO 10.5 MG/DL

 SIGNIFICANCE OF IONISED CALCIUM

1] Blood clotting
2] MAJOR INTRACELLULAR MESSENGER :
-For muscle contraction [cardiac,skeletal]
-For exocytosis of secretory granules in neuronal synapses
-Second messenger in many cells
 REGULATION OF CALCIUM LEVELS
 AT 3 ORGANS :

1] Small intestine : absorption from gut

2] Kidney : Calcium filtered through nephron and excreted in
urine
3] Bone : Major storage site for calcium
 HORMONE REGULATORS

1] CALCITONIN
-Secreted from C-cells of thyroid glands
-Increased plasma calcium stimulates C-cells to synthesize and release
calcitonin

 Lowers calcium in the blood

 Promotes calcium deposition into bone
 Inhibits bone resorption by osteoclasts
 2] PARATHYROID HORMONE

 Secreted from chief cells of parathyroid glands

Increases calcium in the blood

 Increases calcium resorption from bone
-by stimulating osteoclasts
-by increasing number of osteoclasts
 Increases calcium absorption in nephrons of kidney
 3] VITAMIN D

 Increases calcium and phosphate absorption from kidney

 Increases calcium and phosphate absorption from intestine

 OVERALL : Increases serum calcium and phosphate absorption

 HYPERCALCEMIA
N/L SERUM CALCIUM LEVEL – 8.5 -10.5 MG/DL

HYPERCALCEMIA
MILD-B/W 8.5 TO 12
MODERATE- B/W 12 TO 14
SEVERE >14
 Causes of Hypercalcemia
 1] Parathyroid hormone related
Primary hyperparathyroidism
Tertiary hyperparathyroidism
Lithium therapy induced hyperparathyroidism
Familiar hypercalciuric hypercalcemia

 2] Malignancy related-Eg
Multiple myeloma
Bone metastasis
PTHrP secreting tumours of lungs and kidney
 3] Vitamin D related
Vitamin D intoxication-can be iatrogenic or self administered
Granulomatous diseases-tuberculosis,sarcoidosis

 4] High bone turnover

Hyperthyroidism
Drugs-Like thiazide diuretics
Paget’s disease of bone

 5] Excessive calcium intake

-Milk-alkali syndrome
HYPERPARATHYROIDISM
 CLINICAL FEATURES OF
HYPERPARATHYROIDISM
“moans,bones,stones,abdominal groans”

a] Moans-Psychiatric manifestations : Depression,psychosis,memory

loss,confusion,coma

b] Bones-Arthritis,osteomalacia,osteitis

c] Stones-Renal stones,uremia,polydipsia,polyuria

d] Groans- Constipation,vomiting,peptic ulcer,pancreatitis

 More than 70% diagnosed as an incidental finding

 Nonspecific symptoms : in 50% patients

“ Anorexia,nausea,vomiting,constipation,weakness,weight
loss,pain,poor concentration,memory loss and
depression ”
 Renal manifestations :

1] Reccurent renal calculi-usually calcium oxalate or calcium phosphate

2] Nephrocalcinosis : Deposition of calcium salts in renal parenchyma

3] Polyuria and polydipsia

4] Loss of renal function : uremia,hyperuricemia,hyperchloremic acidosis

and dilute urine
 Skeletal manifestations :
-Bone pain,osteopenia,osteoporosis,fractures and deformity
-Localised bone swelling called brown tumour eg: mandible

 Other manifestations :
-Hypertension
-Calcification of cornea ,arterial walls and soft tissues of hand
-Peptic ulcers
-Myopathy
 When to suspect MEN Syndrome ?

When there is a family history of hypercalcemia or hyperparathyroidism secondar

to parathyroid adenoma
 INVESTIGATIONS
 BLOOD

Hypercalcemia, Hypophosphatemia with elevated PTH levels

To do renal function tests

 URINE

Hypercalciuria
Increased markers of bone resorption
Urinary pyridinoline,deoxypyridinoline,N-telopeptide of collagen
 ECG FINDINGS
Shortened QT interval
arrhythmias

 IMAGING
Subperiosteal resorption of cortical bone
Skull-Salt and pepper appearance
Bone cysts or brown tumours
Osteoporosis-Preferrential loss of cortical bone
Soft tissue calcification and nephrocalcinosis
Subperiosteal bone resorption Salt and pepper skull
Nephrocalcinosis
 DEXA and CT scan reveal reduced bone density

 To localise tumour :
USG, CT SCAN, Tc 99 SESTAMIBI
Selective neck vein catheterisation
 TREATMENT
 1] TREATMENT OF HYPERCALCEMIA
A]Adequate rehydration with 0.9% normal saline for several days

B]CALCITONIN 200 Units IV 6th HRLY

C]I/V Bisphosphonate –DOC in hypercalcemia of malignancy

D]Steriods like PREDNISOLONE effective in cases like myeloma

C]Oral phosphate 5 gms thrice daily

 SURGERY

Surgical removal in case of adenoma ,hyperplasia etc

 HYPOCALCEMIA

 DECREASE IN CALCIUM LEVELS LESS THAN 8.5 GM/DL

 CAUSES
1] HYPOPARATHYROIDISM-
-Post surgery-thyroidectomy,parathyroidectomy
-Congenital deficiency-Digeorges syndrome
-Idiopathic
2] VITAMIN D DEFICIENCY
-Osteomalacia/rickets
-Vitamin D resistance
3] DRUGS
-Calcitonin
-Bisphophonates
 D] OTHER CAUSES
Acute pancreatitis
Citrated blood in massive transfusion
Low plasma albumin
Malabsorption

 E] INCREASED PHOSPHATE LEVELS

Chronic renal failure
Phosphate therapy
 HYPOPARATHYROIDISM

 Decreased secretion of PTH which manifest as :

1] Hypocalcemia
2] Decreased PTH
3] Neuromuscular hyperactivity
4] Hyperphosphatemia
 CAUSES of HYPOPARATHYROIDISM
 1] SURGICAL- DUE TO REMOVAL OF PARATHYROID GLANDS

2] PSUEDOHYPOPARATHYROIDISM- RESISTANCE OF PTH

3] FUNCTIONAL HYPOPARATHYROIDISM DUE TO

HYPOMAGNESEMIA – magnesium is responsible for PTH release
from gland and for its peripheral action

4] DiGEORGE’S SYNDROME
 CLINICAL FEATURES
 TETANY- muscle spasms due to increased excitability of peripheral nerves

-due to hypocalcemia

CARPOPEDAL SPASM : flexion of wrist, flexion of metacarpophalangeal

joints,extension of interphalangeal joints and adduction of thumb
-called main d’ accoucheur
 STRIDOR
 CONVULSIONS

 CIRCUMORAL PARAESTHESIA -Tingling around mouth

Also tingling in hands and feet
 Signs of LATENT TETANY
 CHVOSTEK’S SIGN :
Tap skin over the facial nerve in front of external auditory
meatus
IT CAUSES IPSILATERAL CONTRACTION OF FACIAL MUSCLES

 TRAUSSEAU’S SIGN :
Inflate BP cuff to more than 20 mm Hg above systolic BP for 3 to
5 minutes and watch for carpopedal spasm
CHVOSTEK’S SIGN
 CARDIAC FINDINGS

 ECG-PROLONGED QT INTERVAL

 HYPOTENSION

 REFRACTORY HEART FAILURE WITH CARDIOMEGALY

 TREATMENT
 FOR TETANY
I/V 10% CALCIUM GLUCONATE
IF REFRACTORY-MAGNESIUM

CALCITRIOL OR ALPHACALCIDIOL
 PSEUDOHYPOPARATHYROIDISM

 DUE TO RESISTANCE OF TARGET ORGANS TO PTH

 MIMICS
FEATURES OF HYPOPARATHYROIDISM WITH HYPOCALCEMIA
AND HYPERPHOSPHATEMIA

 BUT PTH LEVEL IS ELEVATED

THANK YOU