PAUL. N.

• PAUL. N. HARIJANTO,
HARIJANTO,
SpPD-KPTI,FINASIM
SpPD-KPTI,FINASIM
Paul Harijanto, Sp.PD-KPTI
DISORDERS OF THE
PARATHYROID
GLANDS
The parathyroid glands
Disorders of the Parathyroid Glands

Maintenance
Maintenance of of calcium,
calcium, phosphate
phosphate andand
magnesium
magnesium homeostasis
homeostasis is is under
under the
the
influence
influence of
of two
two polypeptide
polypeptide hormones;
hormones;
parathyroid
parathyroid hormone(PTH),
hormone(PTH), and and calcitonin
calcitonin
(CT),
(CT), as
as well
well as
as aa sterol
sterol hormone,
hormone, 1,25
1,25
dihydroxy
dihydroxy cholecalciferol
cholecalciferol (1,25
(1,25 (OH)
(OH)22D
D33..
Disorders of the Parathyroid Glands

These
These hormones
hormones regulate
regulate the
the flow
flow of
of
minerals
minerals inin and
and out
out of
of the
the extracellular
extracellular
fluid
fluid compartments
compartments through
through their
their actions
actions
on
on intestine,
intestine, kidneys,
kidneys, and
and bones
bones..
Disorders of the Parathyroid Glands

The
The PTH
PTH actsacts directly
directly on
on the
the bones
bones and
and
kidneys
kidneys and
and indirectly
indirectly on
on the
the intestine
intestine
through
through its
its effect
effect on
on the
the synthesis
synthesis of
of 1,25
1,25
(OH)
(OH)22D
D33.. Its
Its production
production is is regulated
regulated by
by the
the
concentration
concentration of of serum
serum ionized
ionized calcium.
calcium.
Lowering
Lowering of of the
the serum
serum calcium
calcium levels
levels will
will
induce
induce an
an increased
increased rate
rate of
of parathyroid
parathyroid
hormone
hormone secretion
secretion
Disorders of the Parathyroid Glands

Calcitonin
Calcitonin isis released
released by by the
the “C”
“C” cells
cells
(parafollicular
(parafollicular cells
cells in
in the
the thyroid
thyroid gland)
gland) inin
response
response to to small
small increases
increases in in plasma
plasma
ionic
ionic calcium.
calcium. ItIt acts
acts on
on the
the kidney
kidney and
and
bones
bones toto restore
restore the
the level
level of
of calcium
calcium to to just
just
below
below aa normal
normal setset point
point which
which in in turn
turn
inhibits
inhibits secretion
secretion of of the
the hormone.
hormone.
Disorders of the Parathyroid Glands

Calcitonin
Calcitonin is
is therefore
therefore the
the physiological
physiological
antagonist
antagonist ofof PTH
PTH.. The
The two
two hormones
hormones act
act
in
in concert
concert to
to maintain
maintain normal
normal
concentration
concentration of of calcium
calcium ion
ion in
in the
the
extracellular
extracellular fluid.
fluid.
 Disorders of the parathyroid
glands
• Hyperparathyroidism
Hyperparathyroidism (hypercalcemia)
(hypercalcemia)
• Hypoparathyroidism
Hypoparathyroidism (hypocalcemia)
(hypocalcemia)
• Tumors
Tumors
 Hyperparathyroidism

• Primary
• Secondary
• Tertiary
 Disorders of the Parathyroid
Function
Hyperparathyroidism

Primary
Primary hyperparathyroidismis
hyperparathyroidismis due due to
to
excessive
excessive production
production of of PTH
PTH byby one
one or
or
more
more of of hyperfunctioning
hyperfunctioning parathyroid
parathyroid
glands.
glands. This
This leads
leads to
to hyprcalcemia
hyprcalcemia which
which
fails
fails to
to inhibit
inhibit the
the gland
gland activity
activity in
in the
the
normal
normal manner.
manner.
 Disorders of the Parathyroid
Function
Hyperparathyroidism

The
The cause
cause ofof primary
primary hyperparathyroidism
hyperparathyroidism
is
is unknown.
unknown. A A genetic
genetic factor
factor may
may be
be
involved.
involved. The
The clonal
clonal origin
origin of
of most
most
parathyroid
parathyroid adenomas
adenomas suggests
suggests aa defect
defect
at
at the
the level
level of
of the
the gene
gene controlling
controlling the
the
regulation
regulation and/or
and/or expression
expression ofof
parathyroid
parathyroid hormone.
hormone.
 Disorders of the Parathyroid
Function
Hyperparathyroidism

The
The incidence
incidence ofof the
the disease
disease increases
increases
dramatically
dramatically after
after the
the age
age of
of 50
50 and
and itit is
is 2-4
2-4 folds
folds
more
more common
common in in women.
women.
AA single
single adenoma
adenoma occurs
occurs inin about
about 80%
80% of of
patients
patients with
with primary
primary hyperparathyroidism.
hyperparathyroidism. Four Four
glands
glands hyprplasia
hyprplasia account
account for
for 15-20%
15-20% of of cases.
cases.
AA parathyroid
parathyroid carcinoma
carcinoma could
could be
be the
the etiology
etiology in
in
aa rare
rare incidence
incidence of
of less
less then
then 1%.
1%.
 Disorders of the Parathyroid
Function
Clinical Features:

The
The two
two major
major sites
sites of
of potential
potential complications
complications
are
are the
the bones
bones and
and the
the kidneys.
kidneys.
The
The kidneys
kidneys may
may have
have renal
renal stones
stones
(nephrolithiasis)
(nephrolithiasis) oror diffuse
diffuse deposition
deposition of
of
calcium-phosphate
calcium-phosphate complexes
complexes in in the
the parachyma
parachyma
(nephrocalcinosis)
(nephrocalcinosis).. NowNow aa days
days such
such
complications
complications are
are seen
seen less
less commonly
commonly andand
around
around 20%
20% of
of patients
patients or or less
less show
show such
such
complications.
complications.
 Disorders of the Parathyroid
Function
Clinical Features:

In
In skeleton
skeleton aa condition
condition called
called osteitis
osteitis fibrosa
fibrosa
cystica
cystica could
could occur
occur with
with subperiosteal
subperiosteal
resorption
resorption of
of the
the distal
distal phalanges,
phalanges, distal
distal
tappering
tappering of
of the
the clavicles,
clavicles, aa “salt
“salt and
and pepper”
pepper”
appearance
appearance of of the
the skull
skull as
as well
well as
as bone
bone cysts
cysts
and
and brown
brown tumors
tumors of of the
the long
long bones.
bones. Such
Such overt
overt
bone
bone disease
disease even
even though
though typical
typical of
of primary
primary
hyperparathyroidism
hyperparathyroidism is is very
very rarely
rarely encountered.
encountered.
 Disorders of the Parathyroid
Function
Clinical Features:

Now
Now aa days
days almost
almost 90%
90% of
of diagnosed
diagnosed
cases
cases in
in the
the developed
developed countries
countries are
are
picked
picked up
up by
by routine
routine screening
screening for
for calcium
calcium
level
level using
using the
the new
new automated
automated machines.
machines.
 Disorders of the Parathyroid
Function
Clinical Features:

Other
Other symptoms
symptoms include
include muscle
muscle
weakness,
weakness, easy
easy fatigability,
fatigability, peptic
peptic ulcer
ulcer
disease,
disease, pancreatitis,
pancreatitis, hypertension,
hypertension, gout
gout
and
and pseudogout
pseudogout asas well
well as
as anemia
anemia and
and
depression
depression have
have been
been associated
associated with
with
primary
primary hyperparathyroidism.
hyperparathyroidism.
Differential Diagnosis
Causes of Hypercalcemia
Parathyroid - related Vitamin D – related

1.
1. Primary
Primary 1.
1. Vitamin
Vitamin DD
hyperparathyroidism
hyperparathyroidism intoxication
intoxication
A.
A. Solitary
Solitary adenomas
adenomas 2.
2. 1,25(OH)2D;
1,25(OH)2D;
B.
B. Multiple
Multiple endocrine
endocrine sarcoidosis
sarcoidosis and
and
neoplasia
neoplasia other
other granulomatous
granulomatous
2.
2. Lithium
Lithium therapy
therapy diseases
diseases
3.
3. Familial
Familial 3.
3. Idiopathic
Idiopathic
hypocalciuric
hypocalciuric hypercalcemia
hypercalcemia oror
hypercalcemia
hypercalcemia infancy
infancy
Differential Diagnosis
Causes of Hypercalcemia
Associated with high
Malignancy - related bone turnover
1.
1. Solid
Solid tumor
tumor with
with 1.
1. Hyperthyroidism
Hyperthyroidism
metastases(breast)
metastases(breast) 2.
2. Immobilization
Immobilization
2.
2. Solid
Solid tumor
tumor with
with 3.
3. Thiazides
Thiazides
humoral
humoral mediation
mediation of
of 4.
4. Vitamin
Vitamin AA intoxication
intoxication
hypercalcemia
hypercalcemia (lung
(lung
kidney) Assocated
Assocated with
with Renal
Renal
kidney)
Failure:
Failure:
3.
3. Hematologic
Hematologic
malignancies 1.
1. Severe
Severe secondary
secondary
malignancies (multiple
(multiple
myeloma, hyperparathyroidism
hyperparathyroidism
myeloma, lymphoma,
lymphoma,
leukemia)
leukemia) 2.
2. Aluminum
Aluminum intoxication
intoxication
3.
3. Milk
Milk alkali
alkali syndrome
syndrome
 Diagnosis

The
The presence
presence of
of established
established
hypercalcaemia
hypercalcaemia in
in more
more than
than one
one serum
serum
measurement
measurement accompanied
accompanied by by elevated
elevated
immunoreactive
immunoreactive PTH
PTH is
is characteristic
characteristic
(iPTH)
(iPTH)
Diagnosis
Serum
Serum phosphate
phosphate is is usually
usually lowlow but
but may
may
be
be normal.
normal. Hypercalcaemia
Hypercalcaemia is is common
common
and
and blood
blood alkaline
alkaline phosphatase
phosphatase (of (of bone
bone
origin)
origin) and
and the
the urinary
urinary hydroxyproline
hydroxyproline
concentrations
concentrations are are commonly
commonly elevated
elevated
when
when the
the bones
bones areare involved.
involved.
Nephrogenous
Nephrogenous CAMP CAMP is is elevated
elevated in in about
about
80%
80% ofof patients
patients but
but the
the test
test is
is rarely
rarely used
used
because
because of of technical
technical difficulties
difficulties
 Other Diagnostic tests
The Glucocortisoid suppression test:

The
The heypercalcaemic
heypercalcaemic of of non-parathyroid
non-parathyroid
origin
origin e.g.,
e.g., vitamin
vitamin D D intoxication,
intoxication,
sarcoidosis
sarcoidosis and
and lymphoproliferative
lymphoproliferative
syndromes
syndromes generally
generally respond
respond toto the
the
administration
administration ofof prednisolone
prednisolone in in aa dose
dose of
of
40-60
40-60 mg
mg daily
daily for
for 10
10 days
days by
by aa decrease
decrease
in
in serum
serum calcium
calcium level.
level.
 Other Diagnostic tests
The Glucocortisoid suppression test:

The
The response
response is is unusual
unusual in in hypercalcaemia
hypercalcaemia
secondary
secondary to to primary
primary hyperparathyroidism
hyperparathyroidism and and
ectopic
ectopic PTH
PTH production.
production.
AA positive
positive test
test result
result i.e.
i.e. significant
significant decrease
decrease in in
serum
serum calcium
calcium is is aa contraindication
contraindication to to neck
neck
exploration
exploration and
and signals
signals thethe need
need for
for
investigation
investigation for
for aa non-parathyroid
non-parathyroid cause
cause of
of the
the
hypercalcaemia.
hypercalcaemia.
 Other Diagnostic tests
Radiograph:

Plain
Plain X-ray
X-ray of
of hands
hands can
can be
be diagnostic
diagnostic
showing
showing subperiosteal
subperiosteal bone
bone resorption
resorption
usually
usually on
on the
the radial
radial surfacy
surfacy of
of the
the distal
distal
phalanx
phalanx with
with distal
distal phalangeal
phalangeal tufting
tufting as
as
well
well as
as cysts
cysts formation
formation and
and generalzed
generalzed
osteopenia.
osteopenia.
 Other Diagnostic tests
Pre-operative localization of the abnormal
parathyroid gland(s):
• Ultrasonography
Ultrasonography
• MRI
MRI
• CT
CT
• Thallium 201 –
Thallium 201 – Tehcnichum 99m scan
Tehcnichum99m scan
(subtraction
(subtraction study)
study)
 Treatment

A
A large
large proportion
proportion of
of patients
patients have
have
“biochemical”
“biochemical” hyperparathyroidism
hyperparathyroidism but but
with
with prolonged
prolonged follow
follow up
up they
they progress
progress toto
overt
overt clinical
clinical presentation.
presentation. Resection
Resection ofof
the
the parathyroid
parathyroid lesion
lesion is
is curative
curative with
with
recurrences
recurrences observed
observed mainly
mainly in
in the
the
multiple
multiple glandular
glandular disease.
disease.
 Medical Treatment of the
hypercalcaemia

In
In acute
acute severe
severe forms
forms the
the main
main stay
stay of
of
therapy
therapy is
is adequate
adequate hydration
hydration with
with saline
saline
and
and forced
forced diuresis
diuresis by
by diuretics
diuretics to
to increase
increase
the
the urinary
urinary excretion
excretion of
of calcium
calcium rapidly
rapidly
along
along with
with sodium
sodium and
and prevent
prevent its
its
reabsorption
reabsorption byby the
the renal
renal tubules.
tubules.
 Other agents

• Glucocostiroids
Glucocostiroids
• In
In hypercalcaemia
hypercalcaemia associated
associated the
the
hematological
hematological malignant
malignant neoplasms
neoplasms
• Mythramycin
Mythramycin
• A
A toxic
toxic antibiotics
antibiotics which
which inhibit
inhibit bone
bone
resorption
resorption and
and is
is used
used in
in hematological
hematological and
and
solid
solid neoplasms
neoplasms causing
causing hypercalcaemia.
hypercalcaemia.
 Other agents

• Calcitonin
Calcitonin
• Also
Also inhibit
inhibit osteoclast
osteoclast activity
activity and
and prevent
prevent
bone
bone resorption
resorption
• Bisphosphonates
Bisphosphonates
• They
They are
are given
given intravenously
intravenously or
or orally
orally to
to
prevent
prevent bone
bone resorption.
resorption.
 Other agents

• Phosphate
Phosphate
• Oral
Oral phosphate
phosphate can
can be
be used
used as
as anan
antihypercalcaemic
antihypercalcaemic agent
agent and
and is
is commonly
commonly
used
used as
as aa temporary
temporary measure
measure during
during
diagnostic
diagnostic workup.
workup.
• Estrogen
Estrogen
• ItIt also
also decrease
decrease bone
bone resorption
resorption and
and can
can be
be
given
given to to postmenopausal
postmenopausal women
women with
with primary
primary
hyperparathyroidism
hyperparathyroidism using
using medical
medical therapy
therapy
 Surgery

• Surgical
Surgical treatment
treatment should
should be
be considered
considered in in
all
all cases
cases with
with established
established diagnosis
diagnosis ofof
primary
primary hyperparthyroidism.
hyperparthyroidism.
• During
During surgery
surgery the
the surgeon
surgeon identifies
identifies all
all
four
four parathyroid
parathyroid glands
glands (using
(using biopsy
biopsy ifif
necessary)
necessary) followed
followed by
by the
the removal
removal of of
enlarged
enlarged parathyroid
parathyroid or
or 33 ½
½ glands
glands in
in
multiple
multiple glandular
glandular disease.
disease.
 Other Complications

• Deterioration
Deterioration of
of renal
renal function
function
• Metabolic
Metabolic disturbance
disturbance e.g.
e.g. hypomagnesia,
hypomagnesia,
pancreatitis,
pancreatitis, gout
gout or
or pseudogout
pseudogout
 Secondary hyperparathyroidism

An
An increase
increase inin PTH
PTH secretion
secretion which
which is
is
adaptive
adaptive and
and unrelated
unrelated toto intrinsic
intrinsic disease
disease
of
of the
the parathyroid
parathyroid glands
glands isis called
called
secondary
secondary hyperparathyroidism.
hyperparathyroidism. This This is
is
due
due toto chronic
chronic stimulation
stimulation ofof the
the
parathyroid
parathyroid glands
glands byby aa chronic
chronic decrease
decrease
in
in the
the ionic
ionic calcium
calcium level
level in
in the
the blood
blood
 Major causes of chronic hypocalcemia
other than hypoparathyroidism

• Dietary
Dietary deficiency
deficiency ofof vitamin
vitamin D
D or
or calcium
calcium
• Decreased
Decreased intestinal
intestinal absorption
absorption of
of vitamin
vitamin
D
D or
or calcium
calcium due
due to
to primary
primary small
small bowel
bowel
disease,
disease, short
short bowel
bowel syndrome,
syndrome, and
and post-
post-
gastrectomy
gastrectomy syndrome.
syndrome.
• Drugs
Drugs that
that cause
cause rickets
rickets or
or osteomalacia
osteomalacia
such
such asas phenytoin,
phenytoin, phenobarbital,
phenobarbital,
cholestyramine,
cholestyramine, andand laxative.
laxative.
 Major causes of chronic hypocalcemia
other than parathyroprival
hypoparathyroidism

• States
States of
of tissue
tissue resistance
resistance to
to vitamin
vitamin D
D
• Excessive
Excessive intake
intake of
of inorganic
inorganic phosphate
phosphate
compunds
compunds
• Psudohypoparathyroidism
Psudohypoparathyroidism
• Severe
Severe hypomagnesemia
hypomagnesemia
• Chronic
Chronic renal
renal failure
failure
 Hypoparathyroidism

Deficient
Deficient secretion
secretion ofof PTH
PTH which
which
manifests
manifests itself
itself biochemically
biochemically by by
hypocalcemia,
hypocalcemia, hyperphospatemia
hyperphospatemia
diminished
diminished or or absent
absent circulating
circulating iPTH
iPTH and
and
clinically
clinically the
the symptoms
symptoms of of neuromuscular
neuromuscular
hyperactivity.
hyperactivity.
 Hypoparathyroidism
Causes:
• Surgical
Surgical hypoparathyroidism
hypoparathyroidism –– the
the
commonest
commonest
• After
After anterior
anterior neck
neck exploration
exploration for
for
thyroidectomy,
thyroidectomy, abnormal
abnormal parathyroid
parathyroid gland
gland
removal,
removal, excision
excision of
of aa neck
neck lesion.
lesion. ItIt could
could bebe
due
due to
to the
the removal
removal of
of the
the parathyroid
parathyroid glands
glands
or
or due
due toto interruption
interruption of
of blood
blood supply
supply to to the
the
glands.
glands.
 Hypoparathyroidism
Causes:
• Idiopathic
Idiopathic hypoparathyroidism
hypoparathyroidism
• AA form
form occuring
occuring atat an
an early
early age
age (genetic
(genetic
origin)
origin) with
with autosomal
autosomal recessive
recessive mode
mode ofof
transmission
transmission “multiple
“multiple endocrine
endocrine deficiency
deficiency ––
autoimmune-candidiasis
autoimmune-candidiasis (MEDAC)
(MEDAC) syndrome”
syndrome”
• ““Juvenile
Juvenile familial
familial endocrinopathy”
endocrinopathy”
• ““Hypoparathyroidism
Hypoparathyroidism –– Addisson’s
Addisson’s disease
disease ––
mucocutaneous
mucocutaneous candidiasis
candidiasis (HAM)
(HAM) syndrome”
syndrome”
 Hypoparathyroidism
Causes:
• Idiopathic
Idiopathic hypoparathyroidism
hypoparathyroidism
• Circulating
Circulating antibodies
antibodies for
for the
the parathyroid
parathyroid
glands
glands and
and the
the adrenals
adrenals are
are frequently
frequently
present.
present.
• Other
Other associated
associated disease:
disease:
•• Pernicious
Pernicious anemia
anemia
•• Ovarian
Ovarian failure
failure
•• Autoimmune
Autoimmune thyroiditis
thyroiditis
•• Diabetes
Diabetes mellitus
mellitus
 Hypoparathyroidism
Causes:
• Idiopathic
Idiopathic hypoparathyroidism
hypoparathyroidism
• The
The late
late onset
onset form
form occurs
occurs sporadically
sporadically
without
without circulating
circulating grandular
grandular autoantibodies.
autoantibodies.
• Functional
Functional hypoparathyroidism
hypoparathyroidism
• In
In patients
patients who
who has
has chronic
chronic hypomagesaemia
hypomagesaemia
of
of various
various causes.
causes.
• Magnesium
Magnesium is is necessary
necessary for
for the
the PTH
PTH release
release
from
from the
the glands
glands and
and also
also for
for the
the peripheral
peripheral
action
action of
of the
the PTH.
PTH.
 Hypoparathyroidism
Clinical Features:
A.
A. Neuromuscular
Neuromuscular
• The
The rate
rate of
of decrease
decrease inin serum
serum calcium
calcium is
is the
the
major
major determinant
determinant forfor the
the development
development of of
neuromuscular
neuromuscular complications.
complications.
• When
When nerves
nerves are
are exposed
exposed to to low
low levels
levels of
of
calcium
calcium they
they show
show abnormal
abnormal neuronal
neuronal
function
function which
which may
may include
include decrease
decrease
threshold
threshold ofof excitation,
excitation, repetitive
repetitive response
response
to
to aa single
single stimulus
stimulus and
and rarely
rarely continuous
continuous
activity.
activity.
 Hypoparathyroidism
Clinical Features:
A.
A. Neuromuscular
Neuromuscular
•• Parathesia
Parathesia
•• Tetany
Tetany
•• Hyperventilation
Hyperventilation
•• Adrenergic
Adrenergic symptoms
symptoms
•• Convulsion
Convulsion (More
(More common
common in in young
young people
people andand itit
can
can take
take the
the form
form of
of either
either generalized
generalized tetany
tetany
followed
followed byby prolonged
prolonged tonic
tonic spasms
spasms or
or the
the typical
typical
epileptiform
epileptiform seizures.
seizures.
•• Signs
Signs of
of latent
latent tetany
tetany
•• Chvostek
Chvostek sign
sign
•• Trousseau
Trousseau sign
sign
•• Extrapyramidal
Extrapyramidal signs
signs (due
(due to
to basal
basal ganglia
ganglia calcification)
calcification)
 Hypoparathyroidism
Clinical Features:
B.
B. Other
Other clinical
clinical manifestation
manifestation
1.
1. Posterio
Posterio lenticular
lenticular cataract
cataract
2.
2. Cardiac
Cardiac manifestation:
manifestation:
Prolonged
Prolonged QTQT interval
interval in
in the
the ECG
ECG
Resistance
Resistance toto digitalis
digitalis
Hypotension
Hypotension
Refractory
Refractory heart
heart failure
failure with
with cardiomegally
cardiomegally
can
can occur.
occur.
 Hypoparathyroidism
Clinical Features:
B.
B. Other
Other clinical
clinical manifestation
manifestation
3.
3. Dental
Dental Manifestation
Manifestation
Abnormal
Abnormal enamel
enamel formation
formation with
with delayed
delayed or
or
absent
absent dental
dental eruption
eruption and
and defective
defective dental
dental
root
root formation.
formation.
4.
4. Malabsorption
Malabsorption syndrome
syndrome
Presumably
Presumably secondary
secondary toto decreased
decreased
calcium
calcium level
level and
and may
may lead
lead to
to steatorrhoea
steatorrhoea
with
with long
long standing
standing untreated
untreated disease.
disease.
 Hypoparathyroidism
Diagnosis:

In
In the
the absence
absence of of renal
renal failure
failure the
the
presence
presence ofof hypocalcaemia
hypocalcaemia with with
hyperphosphataemia
hyperphosphataemia is is virtually
virtually
diagnostic
diagnostic of
of hypoparathyroidism.
hypoparathyroidism.
Undetectable
Undetectable serumserum iPTH
iPTH confirms
confirms the
the
diagnosis
diagnosis or
or itit can
can be
be detectable
detectable ifif the
the
assay
assay is
is very
very sensitive.
sensitive.
 Hypoparathyroidism
Treatment:

The
The mainstay
mainstay ofof treatment
treatment is is aa
combination
combination ofof oral
oral calcium
calcium with
with
pharmacological
pharmacological doses
doses of
of vitamin
vitamin D D or
or its
its
potent
potent analogues.
analogues. Phosphate
Phosphate restriction
restriction
in
in diet
diet may
may also
also be
be useful
useful with
with or or without
without
aluminum
aluminum hydroxide
hydroxide gelgel to
to lower
lower serum
serum
phosphate
phosphate level.
level.
Emergency Treatment for Hypocalcaemic
Tetany:

Calcium
Calcium should
should be
be given
given parenterally
parenterally till
till
adequate
adequate serum
serum calcium
calcium level
level is
is
obtained
obtained and
and then
then vitamin
vitamin DD
supplementation
supplementation with
with oral
oral calcium
calcium should
should
be
be initiated.
initiated.
Emergency Treatment for Hypocalcaemic
Hungry bone syndrome:

In
In patients
patients with
with hyperparathyroidism
hyperparathyroidism and and
severe
severe bone
bone disease
disease who
who undergo
undergo
successful
successful parathyroidectomy
parathyroidectomy
hypocalcaemia
hypocalcaemia maymay be
be severe
severe and
and
parenteral
parenteral calcium
calcium infusion
infusion with
with later
later
supplementation
supplementation with
with oral
oral calcium
calcium and
and
vitamin
vitamin D.
D.
 Pseudohypoparathysoidism and
Pseudopseudohypoparathyroidism

A
A rare
rare familial
familial disorders
disorders with
with target
target tissue
tissue
resistance
resistance to
to PTH.
PTH. There
There isis
hypocalcaemia,
hypocalcaemia, hyperphosphataemia,
hyperphosphataemia,
with
with increased
increased parathyroid
parathyroid gland
gland
function.
function. There
There is is also
also aa variety
variety of
of
congenital
congenital defects
defects in in the
the growth
growth and
and
development
development of of skeleton
skeleton including:
including:
•• Short
Short statue
statue
•• Short
Short metacarpal
metacarpal and
and metatarsal
metatarsal bones
bones