Clinical Manifestations of Primary Hyperparathyroidism (PHPT)

• Despite what most of the literature reports:
  • PHPT is symptomatic in more than 95% of the cases:
    • If proper attention is payed to the subtle symptoms and signs that this disease can produce due to the fluctuating calcium levels
• The “classic”pentad of PHPT:
  • Kidney stones, Painful bones, Abdominal groans, Psychic moans, and Fatigue overtones:
    • Is rarely seen today since the advent and general use of automated blood analyzers in the early 1970s

• Today most patients present with:
  • Fatigue (# 1 symptom)
  • General malaise
  • Decrease levels of energy
  • Anxiety
  • Irritability leading to decrease social interaction
  • Depression (10% of cases)
  • Memory loss
  • Decrease concentration
  • Decrease ability to learn new things
  • Decrease ability to complete daily tasks at home
  • Decrease ability to complete daily tasks at work
  • Decrease social interaction
  • Insomnia
  • Arthralgia’s (32% of the cases)
  • Myalgia’s (14% to 41% of the cases)
  • Bone pain
  • Muscle weakness (specially proximal muscle groups)
  • Intermittent headaches
  • Polydipsia
  • Polyuria
  • Nocturia
  • Nausea (24% of the cases)
  • Anorexia (15% of the cases)
  • Non-specific abdominal pain
  • Heartburn (30% of the cases)
  • Constipation (33% of the cases)
  • Palpitations
  • Arrhythmias (usually atrial fibrillation)
  • Elevated blood pressure
  • Thinning of the hair (specially in women in the frontal region)
  • Pruritus

• Patients with PHPT also tend to score lower than healthy controls when evaluated by general multidimensional health assessment tools such as the Medical Outcomes Study Short-Form Health Survey(SF-36) and other specific questionnaires.
• PHPT that is truly “asymptomatic” is a rare occurrence:
  • Seen in less than five percent of patients:
    • This is important when talking about management based on current guidelines
• Patients with PHPT have some degree of renal dysfunction or symptoms:
  • In approximately 80% of the cases:
    • The renal manifestations implicated with PHPT are:
      • Decreased glomerular filtration rate
      • Hypercalciuria
      • Nephrolithiasis:
        • Nephrolithiasis was previously reported in approximately 40% to 80% of patients but now occur only in about 20% to 25% of the cases:
          • The pathophysiology is thought to be related to the filtered load of calcium in the glomerulus that increases proportionately with the degree of hypercalcaemia
        • Most renal stones in patients with PHPT are composed of calcium oxalate, although slightly alkaline urine may favor the precipitation of calcium phosphate stones:
          • Stone formers are more likely to be hypercalciuric, but less than one-third of the hypercalciuric patients with PHPT actually develop renal stones
        • Hypercalciuria is not a predictor of nephrolithiasis in patients with PHPT and is no longer considered as an indication for surgery
      • Nephrocalcinosis
      • Impaired urinary concentrating ability sometimes leading to polyuria, polydipsia, and nocturia
      • Reduced fractional phosphate reabsorption leading to hypophosphatemia
      • Increased urinary exertion of magnesium

Rodrigo Arrangoiz MS, MD, FACS, FSSO head and neck surgeon that specializes in parathyroid diseases that is a member of Mount Sinai Medical Center

• Rodrigo Arrangoiz MS, MD, FACS, FSSO is a member of the American Thyroid Association:

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