CALCIUM AND PARATHYROID DISORDERS.pptx

Calcium and parathyroid disorders
Abhijith

1. CALCIUM AND PARATHYROID DISORDERS

2. 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]

3. 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

4. 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

5. 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

6. 2] PARATHYROID HORMONE Secreted from chief cells of parathyroid glands Increases calcium in the bloo d Increases calcium resorption from bone -by stimulating osteoclasts -by increasing number of osteoclasts Increases calcium ab sorption in nephrons of kidney

7. 3] VITAMIN D Increases calcium and phosphate absorption from kidney Increases calcium and phosphate absorption from intestine OVERALL : Increases serum calcium and phosphate absorption

8. 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

9. 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

10. 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

11. HYPERPARATHYROIDISM

12. 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

13. More than 70% diagnosed as an incidenta l finding Nonspecific symptoms : in 50% patients “ Anorexia,nausea,vomiting,constipation,weakness,weight loss,pain,poor concentration,memory loss and depression ”

14. 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

15. 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

16. When to suspect MEN Syndrome ? When there is a family history of hypercalcemia or hyperparathyroidism secondary to parathyroid adenoma

17. 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

18. 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

19. Subperiosteal bone resorptio n Salt and pepper skull

20. Nephrocalcinosis

21. DEXA and CT scan reveal reduced bone density To localise tumour : USG, CT SCAN, Tc 99 SESTAMIBI Selective neck vein catheterisation

22. TREATMENT 1] TREATMENT OF HYPERCALCEMIA A]Adequate rehydration with 0.9% normal saline for several days B]CALCITONIN 200 Units IV 6 th 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

23. SURGERY Surgical removal in case of adenoma ,hyperplasia etc

24. HYPOCALCEMIA DECREASE IN CALCIUM LEVELS LESS THAN 8.5 GM/DL

25. 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

26. D] OTHER CAUSES Acute pancreatitis Citrated blood in massive transfusion Low plasma albumin Malabsorption E] INCREASED PHOSPHATE LEVELS Chronic renal failure Phosphate therapy

27. HYPOPARATHYROIDISM Decreased secretion of PTH which manifest as : 1] Hypocalcemia 2] Decreased PTH 3] Neuromuscular hyperactivity 4] Hyperphosphatemia

28. 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

29. 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

30. STRIDOR CONVULSIONS CIRCUMORAL PARAESTHESIA - Tingling around mouth Also tingling in hands and feet

31. 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

32. CHVOSTEK’S SIGN

33. CARDIAC FINDINGS ECG-PROLONGED QT INTERVAL HYPOTENSION REFRACTORY HEART FAILURE WITH CARDIOMEGALY

34. TREATMENT FOR TETANY I/V 10% CALCIUM GLUCONATE IF REFRACTORY-MAGNESIUM CALCITRIOL OR ALPHACALCIDIOL

35. PSEUDOHYPOPARATHYROIDISM DUE TO RESISTANCE OF TARGET ORGANS TO PTH MIMICS FEATURES OF HYPOPARATHYROIDISM WITH HYPOCALCEMIA AND HYPERPHOSPHATEMIA BUT PTH LEVEL IS ELEVATED

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