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Clinical features

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

"Bones, moans and stones" is the classical description of hyperparathyroidism but such clear cases are uncommon in the Wesren world.
Patients with primary hyperparathyroidism may:

  • present with symptoms of hypercalcaemia or PTH excess
  • be asymptomatic (hypercalcaemia detected incidentally) - more commonly seen

Symptomatic hypercalcaemia:

  • in the Western world this variant accounts for only 20-30% of patients while in the developing countries most patients still present with symptomatic primary hyperparathyroidism
  • symptoms may include:
    • renal manifestations - nephrolithiasis (most common), polyuria, and renal insufficiency
    • bone pathology
      • fragility fractures
      • low bone mineral density, with preferential bone loss at sites rich in cortical bone
      • osteitis fibrosa cystic - classical primary hyperparathyroid bone disease characterised by generalised demineralisation of the skeleton, subperiosteal bone resorption, and the development of bone cysts
    • gastrointestinal symptoms - nausea, peptic ulcer disease, constipation, pancreatitis (uncommon)
    • neurospsychiatric disturbances - depression, lethargy, and decreased cognitive and social function which may progress into psychosis and coma in severe hypercalcaemia,
    • gout and pseudogout – may be associated with primary hyperparathyroidism
    • cardiovascular manifestations
      • seen in severe primary hyperparathyroidism
      • includes left ventricular hypertrophy, cardiac calcification, conduction abnormalities, endothelial dysfunction, and a shortened QT interval.

Asymptomatic hypercalcaemia

  • diagonsed during routine screening or during assessement for low bone mineral density
  • patienta may have non specific symptoms of mild hypecalcaemia e.g. - fatigue, mild depression or malaise

Normocalcaemic hyperparatyroidism

  • patients with normal serum calcium but elevated PTH
  • may be identified during evaluation of osteoporosis or a fragility fracture (a raised PTH is identified on further assessment of the osteoporosis)
  • vitamin D inadequacy and renal impairment which present with increased PTH values and normal serum calcium should be excluded

Features attributable to hypercalcaemia may be evident in primary and tertiary hyperparathyroidism.

  • in secondary hyperparathyroidism, the clinical picture may be complicated by hypocalcaemia. In chronic renal failure, co-existent osteomalacia results in renal osteodystrophy

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