Skeletal Manifestations of Primary Hyperparathyroidism (PHPT)

  • Skeletal manifestations including osteopenia, osteoporosis, and osteitis fibrosa cystica:
    • Are found in approximately 15% of patients with PHPT
  • PHPT is linked with a reduction in bone mineral density (BMD):
    • Particularly in the cortical bone:
      • Such as in the distal third of the radius
    • In the lumbar region, composed all most exclusively by trabecular bone, and in the femoral region, composed by cortical and trabecular bone:
      • The decrease in BMD is less severe
  • Osteitis fibrosa cystica:
    • A skeletal manifestation that is rarely seen today:
      • Seen in less than five percent of patients with PHPT
    • Is caused by an increase in bone turnover:
      • Can be determined by finding an:
        • Elevated serum alkaline phosphatase level
    • The radiologic findings seen in patients with PHPT with bone disease are characterized by:
      • Subperiosteal resorption:
        • Most obvious on the radial aspect of the middle phalanx of the second and third fingers
      • Bone cysts
      • Tufting of the distal phalanges:
        • Which are best evaluated on plain x-rays of the hands
      • Brown or osteoclastic tumors:
        • Caused by the accumulations of osteoclasts and fibrous tissue:
        • Brown tumors have a slightly greater incidence in PHPT than in secondary HPT:
          • 3% versus 2%
        • In patients with chronic kidney disease:
          • Persistent and excessive urinary calcium elimination:
            • Can lower serum calcium level:
              • And lead to an increase in PTH secretion
        • This results in mobilization of calcium from the bones:
          • Through rapid osteoclastic turnover of bone to maintain normal serum calcium levels
        • In regions where bone loss is exceptionally fast:
          • Hemorrhage, and reparative granulation tissue, with active, vascular, proliferating fibrous tissue may replace the normal marrow contents:
            • Resulting in a brown tumor
        • Hemosiderin imparts the brown color (hence the name of the lesions
      • The skull also may be affected:
        • Appears mottled with a loss of definition of the inner and outer cortices
  • Patients with normal serum alkaline phosphatase levels:
    • Almost never have clinically apparent osteitis fibrosa cystica
  • Bone disease correlates with serum PTH and vitamin D levels
Generalized osteopenia, erosion of the terminal phalangeal tufts and subperiosteal resorption of bone particularly the radial aspects of the 2nd and 3rd middle phalanges.
Brown Tumors
Salt and Pepper Skull

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