Bone disease in primary hyperparathyroidism

Abstract

Bone disease in severe primary hyperparathyroidism (PHPT) is described classically as osteitis fibrosa cystica (OFC). Bone pain, skeletal deformities and pathological fractures are features of OFC. Bone mineral density is usually extremely low in OFC, but it is reversible after surgical cure. The signs and symptoms of severe bone disease include bone pain, pathologic fractures, proximal muscle weakness with hyperreflexia. Bone involvement is typically characterized as salt-and-pepper appearance in the skull, bone erosions and bone resorption of the phalanges, brown tumors and cysts. In the radiography, diffuse demineralization is observed, along with pathological fractures, particularly in the long bones of the extremities. In severe, symptomatic PHPT, marked elevation of the serum calcium and PTH concentrations are seen and renal involvement is manifested by nephrolithiasis and nephrocalcinosis. A new technology, recently approved for clinical use in the United States and Europe, is likely to become more widely available because it is an adaptation of the lumbar spine DXA image. Trabecular bone score (TBS) is a gray-level textural analysis that provides an indirect index of trabecular microarchitecture. Newer technologies, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), have provided further understanding of the microstructural skeletal features in PHPT.

Kidney Stones and Crushed Bones Secondary to Hyperparathyroidism

“…Th e bone manifestations in severe primary hyperparathyroidism, known collectively as osteitis fi brosa cystica, may include bone pain, skeletal deformity, pathological long bone fractures, and brown tumors (2). Bone mineral density is usually extremely low, but is reversible with surgical resection of the tumor.…”

¿Son válidos los criterios quirúrgicos actuales del hiperparatiroidismo primario asintomático?

“…From 1990 up until 2014 some criteria have been published by the "Workshop on surgical indications in asymptomatic primary hyperparathyroidism" [5][6][7][8][9][10] . The clinical and analytical data listed in these are very similar, varying only in some details, such as the change in the densitometric evaluation from the Z-score included in the 1990 criteria 5 to the T-score from 2002 [6][7][8][9] , and the inclusion of fragility fractures from 2008 6,7 . The last consensus in 2014 included the risk of urolithiasis, either analytical or biochemical, as well as the presence of nephrolithiasis or nephrocalcinosis 6 .…”

“…The clinical and analytical data listed in these are very similar, varying only in some details, such as the change in the densitometric evaluation from the Z-score included in the 1990 criteria 5 to the T-score from 2002 [6][7][8][9] , and the inclusion of fragility fractures from 2008 6,7 . The last consensus in 2014 included the risk of urolithiasis, either analytical or biochemical, as well as the presence of nephrolithiasis or nephrocalcinosis 6 . On the other hand, age, below 50 years, and hypercalcemia of 1 mg above the upper limit, have remained unchanged in all the documents.…”

“…In the long term, PHPT may produce a series of complications, such as chronic renal insufficiency, urolithiasis, osteoporosis, fragility fractures and fibrocystic osteopathy [1][2][3][4][5][6] . On over 90% of occasions PHPT is due to an adenoma and surgery is the only curative treatment 3,4 .…”

“…To throw light on this matter a number of position documents have been published [5][6][7][8][9][10] , without there being unanimous agreement [2][3][4]10,11 . Techniques such as bone densitometry help to establish the existence of osteoporosis as a complication 3,6 , and recently a new technique has been introduced, the trabecular bone score (TBS), which is intended to evaluate the integrity and connectivity of the trabeculae of the vertebrae [12][13][14][15] , with some studies having been published which show the early effects of PHPT [14][15][16] . While intervention criteria are a widely used tool when taking a therapeutic decision, on occasion the patient may benefit from surgery in spite of their not strictly meeting these criteria.…”