Parathyroid gland was first described by IVANS AND STORM IN 1880. First parathyroidectomy was performed by FELIX MAMDLE in 1925. EUGENE DUBOIS in 1926 performed first parathyroidectomy at Massachusetts General Hospital at posted in USA, while SMAULE WELLS reported first successful auto transplantation of ….. preserved parathyroid tissue.
Primary hyperparathyroidism in the most important cause of hypercalcemia. It is classified as adenoma, glandular hyperplasia and carcinoma. Secondary hyperplasia is a reactive phenomena mostly due to renal failure. Clinically single gland involvement in adenoma while more then one is hyperplasia. It is difficult to differentiate between the two by light microscopy. Single gland involvement with a normal run of parathyroid tissue is probably an adenoma while multiple gland with total tissue replacement by abnormal cells is hyperplasia. Its cause is not known and sporadic cases seen, but can be inherited done or as a component of familial endocieno pathies including MEM type 1 and 2A.
A symptomatic hyperplasia is the common occurrence now a days in West, though Clark (1989) found only 2 asymptomatic cases out of 103 cases of primary hyperparathyroidism. Now more and more care reports are covering in western literature,, while symptomatic cases are predominantly in India for each, middle each and part of southern hemisphere.
Cope (1966) classically described the symptoms related to nephrolitheasis, bone diseases, abdominal pain, pancreatlitie psychic moans from fatigue, hyper lenis and CNS disturbances. Incidence is about 42 per 1,00,000 population and female to male ratio is 3:1.
Patients and Methods
This study was conducted in M.G.M. Medical College, M.Y. Hospital, and other Associated Hospitals in Indore is last 10years. 32 cases studied. The patients were diagnosed as hyperparathyroidism based on one or more of the following cu…… (1) elevated serum calcium land (>10.5mg.dl) (2) hypercalcemia (>250mg/day for female and >300mg/day for male) and hypophosphatienia (>2.5mg/ml) (3) inappropriately high intact parathyroid hormone – iPTH (>65pq/ml) determined by IRMA (4) Characteristics radio graphic features of PHPT (5) histological evidence after parathyroidectomy. Patient with a suggestion of multiplendocrime neoplania and other associated metabolic disorders were excluded from the study. Medical records of there documented PHPT patients were retrospectively renewed for age, sex, previous medical history, presenting symptoms and signs routine biochemical investigations, radiological findings and histopathological diagnosis. Preoperative localization study included one or more of the following : ultrasonography, CT/MRI Scan and Tc99m technetium or sestamibi scan, whenever indicated. In two patients incidental parathyroid adenoma detected during thyroid surgery, no localization study done before and after surgery study did not reveal any other enlarged parathyroid gland. The results are expressed as mean + I.S.E.
RESULTS :-
Twenty six females (77%) and six males were included in this study. Mean age was 24.4(09-61) years. 46.9% patients were below 20 years and 37.5% patients were below 40 years of age. 14 patients (43.8%) presented with fractures including long bones, riles or vertilere, out of which 8 patients were bed ridden with multiple fractures and other associates symptoms, 14 patients (43.8%) had bilateral naval stones with four patients showing mild to uroderato hydrovaphosa with 20 patients (62.5%) had Urinary symptoms. 2 cases had palpable nodule of parathyroid gland confirmed by radio imaging ………… exploration. Table No. 1 shows the clinical presentation of there 32 patients. Table 2 shows the bio chemical parameters of 30 patients, as in two patients PHPT detected incidentally following Thyroid Surgery. Hyperkdeacmie / Hypophosphaternuma was found in all 30 cases. Sercum Alkaline phophatau was raised in 27 of 20 patients (90%). Mean intact parathyroid hormone (iPTH) was raised in all 30 cases.
Radio imaging techniques proved iveritable in localizing PHTP. Ultrasound localized parathyroid nodule in 26 of 30 cases (86.6%). MRI Scan 5 out of 6 cases (83.3%), and parathyroid scan either sestamilior tetra phosphcire in 11 of 11 cases (100%) (Fig. 1&2)
50 parathyroid glands excised in 32 cases. One case needed second exploration following persistent hypercalcemia. 4 cases had two enlarged parathyroid glands where others were not been identified during surgery required part of the gland transplanted in neck muscles (2 cases)and forearm (2 cases). 25 patients developed hypocalcaemia post operatively. 2 cases were on I.V. calcium for 3 to 4 weeks before accepting and calcium one needed tracheotomy because of senretetany and respiratory distress. Others were given intravenous calcium for 3 to 7 days followed by oral calcium and vit D3 preparation. Patient with Grant cell tumor of Head of Humorous improved in her symptoms following parathyroidectomy.
Before parathyroid surgery two patients underwent nephrotomy/ PCNL (per cutavenus nephrolithology) to relieve urenica. One unusual case (26 m/f) of Giant Cell tumor of head of Humerous (Fig….) underwent excision and prosthesis replacement developed severe vomiting with abdominal pain not responding to usual management. Investigation revealed S-Calcium 14.8, S-phosphorus-3.7, AND Alkaline phosphatose-1963, TC-99m padeducelectride scan showed larged parathyroid gland of more than 2 cm. The same was palpable on clinical examination (Fig…..) Excision of this parathyroid gland improved her symptoms restoring normal calcium level.
DISCUSSION :-
Parathyroid Hormone (PTH) is important in body calcium metabolism along with Vit D Primary hyperparathyroidism is a command endocrine disorder prudent in 0.1 to 0.4 percent of population. The increase prevalence of this disorder was noticed in 1970’s following routine screening of serum calcium levels.(11) SCNA in west. Majority of these patients are asymptomatic and mild symptoms are difficult to relate with PHPT. A large study of primary hypothyroidism oat Mayo clinic of 10 years follow up fail to answer of surgery is necessary in asymptomatic patient. 24 SCNA 87 – Symptomatic PHPT is still the predominant form of the disease in developing countries. Clinical presentation of skeletal manifestation, abdominal pain, renal calculi with urinary symptoms, gastrointestinal and cardiac symptoms, are still prevalent in PHPT, where diagnosis is made following symptomatic patients being investigated(5-Bharsali) as seen in studies by Biyabani, Yones, Nasri and Bhansali. Vit Deficiency in endemic area of some developing countries enhances the ostenties fibrosa cystic and other related disorder in PHPT (9-Bharnali).
Male : female ratio described in literature in month1:2 or 1:3, is in west, while in our series as also in other series in India and other eastern countries male /female ratio 1:4 or more younger age below 40 is predominating in Indian and eastern countries. In our series 88% of patients are below 40 years of age of which 47% are below 20 years.
The mean age in developed countries in 55 to 62 years(10,11). While it is series 22.4 in our series Norin (1947) Dent (1961) Sullivan (1985) reported majority of patients above 40 years. Observation in this series resembles the findings of other series in India (9,14,15 Freepcfic) about means age of below 40 years.
The mean age at presentation is almost two to three decades younger then seen in developed countries. The comparison is of age predominate of the disorder in scientifically not correct as the literature in developed countries include asymptomatic patient forming the majority of patient while in developing countries all patients are symptomatic involving younger age group. It is Vit D deficiency at younger age or genetic dominant disease is difficult to say.(16 papers 9-15)
Musculo Skeletal manifestation in primary parathyroidism (PHPT) is the commonest Symptom is most of the western literature as well in literature17,6 published in India and other countries in this regions.(Bhansali Rao, Kapur) In our series it is 70% with 41% having fractures. Most of the classical oslectis febrosa cystic (OFC) in PHPT used to be a common features in literature in west before 1960 (Cope, Carl) but now seen in few % of cases. IN Indian series ostoprocosis, occasional lytic leicoin, and features are commonly seen in large group by typical ostectis feature cyrtics (ofc) is not seen that commonly. Inspite of high number of bone symptoms and fractures bones some how, this features is less seen in present scenario. Mishra (2001) still feels a large percentage of patients develop osteitis fibrosa cystica. Bhansali found ofc in 58%. Similar high bony involving is reported from other eastern countries22,24 also Hypercalcemia is a state caused by hyper secretions of parathyroid harmone. The same is observed in our study as wide in other series. One previous study is India by Harinarayan (1995) reported normocalcanis in 50% of cases, Vit D deficiency. Hypercalcemia also is the common feature because of hypercalcemia leading to different Urinary symptoms in 50 to 60 percent of cases are with or without send calculus. In this series 62% patients had urinary symptoms of frequency, dysinea, hematuna and buring incline, while 43.8% had Renal Calculus. In other reported series in India 53% patients had renal calculus was prevalent in 50-55% of cases, but the recent literature show less than 10% of PHPT cases had renal calculus Bhansali (2005) reported 70% patients were presented with renal calculus and suggested high hypercalcemia in Indian patients may be the cause of this.
Abdominal pain, dyspepica, vacusea, heart burn with substenal ….. buring and pain of gastroocophaged reflux are common symptom found in more then 50% of PHPT. Such symptoms are less common in Indian patients and so also n developing countries. We did have 34.3% patient having such symptoms. Lack of energy and concentration, anxiety, unit ability, sleeplessness, nervousness and depression due to high calcium level affecting neurogeric cells were found in large number of patients from 50 to 75%. In our series also 43.8% patient had similar symptoms.
High blood pressure is another common symptoms found in large numbers of patients. Similarly other cardiac problem like cardiacpalphilation and arythuries are also not uncommon in western literature (5-6%)(19- S Boman) SCNA 8% 40.6% of our patients had hypertenur.
Preoperative localization by ultrasonography computed tomography scanning (CT), magnetic resonance imaging (M2) and radio aclitide imaging with technetium 99m(Tc-99n), Thallium technetium and setamiter are non invasive procedure available with varied sensecities (SCNA-1995-Page 483) T3-99n sestamidu is sencitune in 90 to 95% of cases. In our series, USG (22% of 31), and MRI (14 of 16) and Tc-99n technetium scan (12 of 12) showed more sensitivity in localizing PHPT then others(SCNA-95).
32 cases underwent operation with excision of 44 parathyroid glands. One case needed second exploration following persistent hypercalcemia. 4 cases had two enlarge parathyroid glands and one case had 3 parathyroid glands, needed its excision with transplantation in 4 cases. Different series show different numbers of single or multiple parathyroid glands involvement with PTHP. Post operative hypocalcemia was found in 20 cases (62.5%) needed I.V. Calcium for 7 to 21 day followed by oral calcium, unlike studia in west(Bomnes – Eurp. Journal of Endocrinology-2004)
Two cases operated for multinodular goitic were found to have one parathyroid gland enlarged and excised, reported as parathyroid adenoma, were not diagnosed preoperatively. Such incidental parathyroid hyperplasia is not uncommon during thyroid surgery.
One unusual care of Giant Cell Tumour in a young female with multiple fractures missed the diagnosis of PHPT because of not doing routine CS Calcium.
