1. CALCIUM HOMEOSTASIS & PARATHYROID DISORDERS
DR. MAHMUDUL HUQUE
HOLY FAMILY RED CRESCENT MEDICAL COLLEGE

3. Calcium Homeostasis
calcium homeostasis is the mechanism by which the body maintains adequate calcium levels. Derangements of this mechanism lead to hypercalcaemia or hypocalcaemia, both of which can have important consequences for health.

4. Normal range:
9–10.5 mg/dL or
2.2–2.6 mmol/L

5. Corrected Ca level
Corrected calcium (mg/dL) = measured total Ca (mg/dL) X (4.0 - serum albumin [g/dL]

6. Hypercalcemia Polyurea, polydipsia Renal colic, lethargy
Anorexia, nausea, dyspepsia
Peptic ulcer, depression, drowsiness
Impaired cognition
Acute/chronic onset
Malignant Hypercalcaemia Ca>12 mg/dl

7. Causes of Hypercalcemia
Abnormal parathyroid gland function
Primary or tertiary hyperparathyroidism
Lithium induced
familial hypocalciuric hypercalcaemia
Malignancy
Lungs, breast, renal, ovarian, colon, Thyroid malignancy.
haematologic malignancy (multiple myeloma, Lymphoproliferative disorders)

8. Contd… Vitamin-D metabolic disorders
hypervitaminosis D (vitamin D intoxication)
elevated 1,25(OH)2D levels (e.g. sarcoidosis)
Others
Thyrotoxicosis – TSH, FT3, FT4
Thiazide use
Paget's disease of the bone
Addison’s disease
severe secondary hyperparathyroidism
milk-alkali syndrome

9. Treatment Hydrate with Normal saline: 4-6L deficient
Diuretics: Look for K, Mg
Salmon calcitonin: BD, 5-8 u/Kg, 3-4 days
BISPHOSPHONATES: Pamidronate & Zoledronic acid
Plicamycine / Gallium nitrate (toxic)
Steroids: 40mg/day In granulomatous sarcoidosis
Haemodialysis
Treat cause

10. Hypercalcaemia
Oral, perioral and acral paresthesias, tingling or 'pins and needles' sensation. This is often the earliest symptom of hypocalcaemia.
Carpopedal Spasm and generalized tetany
Latent tetany: Trousseau sign of latent tetany (eliciting carpal spasm by inflating the blood pressure cuff and maintaining the cuff pressure above systolic).
Chvostek's sign (tapping of the inferior portion of the zygoma will produce facial spasms).
Epilepsy, Psycosis
Papilloedema
Basal ganglia Calcification
Metastatic calcification
Severe Hypocalcaemia <6mg/dl

11. Causes of Hypocalcaemia
Absent parathyroid hormone (PTH)
Hereditary hypoparathyroidism
Following parathyroidectomy
Following thyroidectomy, the parathyroid glands are located very close to the thyroid and are easily injured or even accidentally removed during thyroidectomy
In DiGeorge Syndrome, a disease characterized by the failure of the third and fourth pharyngeal pouches to develop, the parathyroid glands do not form and there is thus a lack of PTH.
Storage – Al, Cu, Fe
Trauma or vascular formation

12. Contd…. Alkalosis: Resp. + Metabolic CRF
Vit. D deficiency, Malabsoption syndrome
Pseudo hypoparathyroidism
Acute pancreatitis
Drug- Ca lowering drugs
Massive Blood transfusion
Osteoblastic metastasis

13. Treatment of Hypocalcaemia
If alkalosis: Rebreath expired air or 5% CO2 in O2 .
10% Calcium gluconate slow IV to keep Ca >7mg/dl till relief.
Oral Calcium: gms elemental Ca, 500 mg of Ca tab.
If serum Ca fall bellow 7mg/dl, give again after 6hrs Ca gluconate Upto 100mg/day.
Tab. 1α in persistant hypo parathyroidism
Magnesium (nalepsin) in calcium resistant persons

14. Hyperparathyroidism Primary: Single adenoma-90% Multiple adenoma-4%
Nodular hyperplasia-5%
Carcinoma-1%
S. Ca
PTH
Secondary:
CRF (specially)
Malabsorption
Osteomalacia & ricket
S.Ca
Tertiary:
Esp. CRF

15. Contd….
Serum biochemical hyper and hypo calcaemia occupies the clinical spectrum of parathyroid disease. So are the features of hyper/hypo calcaemia.

16. Diagnosis Features of hypercalcaemia PTH radio-immuno assay
24 hr urinary calcium increased
Radiology: Osteitis fibrosa cystica,
Pepperpot skull,
Bone cyst- brown tumour
Tumour localisation by- Surgery, USG, CT, Neck catheterisation, PTH measurement, Technetium isotope imaging.

17. Treatment Manage hypercalcaemia Remove the tumour Tagging the remnant
Transplant in symptomatic, young & progressive
Secondary: Calcitriol to suppress PTH
Tertiary: Remove

18. Hypoparathyroidism Hypocalcaemia, signs and symptoms of decreased Ca.
Hyperphosphatemia
Undetectable PTH
Exclude serum Mg deficiency. If (+) Functional Hypoparathyroidism.

19. Hypoparathyroidism It is due to destruction, surgery,
Vascular damage, or
idiopathic as part of poly-glandular failure or agenesis (DiGeorge syndrome)

20. Pseudohypoparathyroidism
Pseudohypoparathyroidism is a condition associated primarily with resistance to the parathyroid hormone. Patients have a low serum calcium and high phosphate, but the parathyroid hormone level (PTH) is actually appropriately high (due to the hypocalcaemia).
Increased PTH + biochemically Low Ca and High PO4 + body stigma.
Features: Short stature, obese with round face, short 4th and 5th metacarpal, mental retardation, defective teeth & bone formation

21. Short stature, obese with round face

22. blunting of the fourth and fifth knuckles of the hand
Short 4th and 5th metacarpals
blunting of the fourth and fifth knuckles of the hand

23. Pseudopseudohypoparathyroidism
Pseudopseudohypoparathyroidism (pseudoPHP) is an inherited disorder, named for its similarity to pseudohypoparathyroidism in presentation. The term pseudopseudohypoparathyroidism is used to describe a condition where the individual has the phenotypic appearance of pseudohypoparathyroidism, but is biochemically normal.
It is sometimes considered a variant of Albright hereditary osteodystrophy.

24. Young woman with short stature, disproportionate shortening of the limbs, generalized obesity, and round, flattened face. Radiograph of the hand showing the shortened 4th and 5th metacarpals

25. Thank You