Bone Disease and Primary Hyperparathyroidism

• Bone disease, including:
  • Osteopenia, osteoporosis, and osteitis fibrosa cystica:
    • Is found in approximately 15% of patients with primary hyperparathyroidism at the time of diagnosis
  • Increased bone turnover:
    • As found in patients with osteitis fibrosa cystica:
      • Can be determined by documenting:
        • Elevated alkaline phosphatase concentration
  • Advanced PHPT with osteitis fibrosa cystica:
    • Now occurs in less than 5% of patients
  • The classic manifestation of PHPT bone disease is:
    • Osteitis fibrosa cystica:
      • Which is characterized clinically by bone pain and radiographically by subperiosteal bone resorption
    • It has pathognomonic radiological findings:
      • Which are best seen on radiographs of the hands:
        • And are characterized by subperiosteal resorption:
          • Most evident in the radial aspect of the middle phalanx of the second and third fingers
        • Bone cysts
        • Tuft formation of the upper part of the distal phalanges
      • Brown or osteoclastic tumors of the long bones:
        • Result from excess osteoclast activity:
          • And consist of collections of osteoclasts intermixed with fibrous tissue and poorly mineralized woven bone
        • The brown coloration is due to:
          • Hemosiderin deposition
      • Tapering of the distal clavicle
    • Patients with normal serum alkaline phosphatase levels:
      • Rarely have clinically apparent osteitis fibrosa cystica
• PHPT typically results in a loss of bone volume:
  • At the cortical bone sites such as:
    • The radius
  • Relative preservation of cancellous bone:
    • As found in vertebral bodies
    • Patients with primary hyperparathyroidism, however:
      • May also have osteoporosis in the lumbar spine that dramatically improves after parathyroidectomy
• Fractures are also more common in patients with primary hyperparathyroidism, and the incidence of fractures:
  • Also decreases after parathyroidectomy:
    • Bone disease is correlated with serum PTH and vitamin D levels

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