clinical features

Last reviewed 01/2018

"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

.Reference:

• (1) Pallan S, Rahman MO, Khan AA. Diagnosis and management of primary hyperparathyroidism. BMJ. 2012;344:e1013