Primary hyperparathyroidism with pancreatitis: experience of management in 5 patients with review of literature

Effect of parathyroidectomy on serum inflammatory and metabolic dysfunction markers in patients with primary hyperparathyroidism

Objective

This study analyzed systemic inflammatory changes reflected by hematologic and biochemical indices in patients with hyperparathyroidism (PHPT) after parathyroidectomy.

Materials and methods

Retrospective study of 70 patients who underwent curative parathyroidectomy for PHPT treatment. Data on clinical presentation, biochemical assays, imaging studies, and postoperative outcomes were collected. Systemic inflammation was quantified using different indices, including the triglyceride-glucose (TyG) index, Fibrosis-4 (FIB-4) score, systemic immune-inflammation index (SII), monocyte-to-high-density lipoprotein cholesterol ratio (MHR), platelet-to-lymphocyte ratio (PLR), and platelet distribution width (PDW).

Results

Significant pre-surgical to post-surgical decreases were observed in serum levels of mean normalized calcium (11 ± 0.65 mg/dL and 9.1 ± 0.42 mg/dL, respectively, p = 0.001) and parathyroid hormone (PTH) (235.5 ± 132.9 and 78.1 ± 60.5 ng/L, respectively, p = 0.001). The inflammatory indices changed substantially, with decreases in SII (from 564.8 ± 257.5 to 516.6 ± 201.1, p = 0.001) and PLR (from 143.0 ± 46.2 to 133.6 ± 38.6, p = 0.001). Additionally, PDW decreased from 52.8 ± 8.2% to 47.5 ± 9.3% (p = 0.001) and MHR increased from 7.19 ± 3.06 to 7.81 ± 3.13 (p = 0.001). No significant changes occurred in other inflammatory markers, including the TyG index (p = 0.431) and FIB-4 score (p = 0.401). Logistic regression analysis identified PDW (odds ratio [OR] 0.920, 95% confidence interval [CI] 0.879-0.963, p = 0.001) and PLR (OR 0.991, 95% CI 0.983-1, p = 0.042) as significant predictors of inflammation.

Conclusions

Successful parathyroidectomy in patients with PHPT reduces systemic inflammation, as evidenced by decreased PDW and PLR. Our results indicate the importance of integrating PDW and PLR in the postoperative assessment of PHPT for monitoring inflammatory activity.

Primary hyperparathyroidism presenting as acute pancreatitis: An institutional experience with review of the literature

BACKGROUND

Acute pancreatitis (AP) presenting as an initial manifestation of primary hyperparathyroidism (PHPT) is uncommon, and its timely diagnosis is crucial in preventing recurrent attacks of pancreatitis.

AIM

To determine the clinical, biochemical, and radiological profile of PHPT patients presenting as AP.

METHODS

This is a retrospective observational study, 51 consecutive patients admitted with the diagnosis of PHPT during January 2010 and October 2021 at a tertiary care hospital in Puducherry, India was included. The diagnosis of AP was established in the presence of at least two of the three following features: abdominal pain, levels of serum amylase or lipase greater than three times the normal, and characteristic features at abdominal imaging.

RESULTS

Out of the 51 consecutive patients with PHPT, twelve (23.52%) had pancreatitis [5 (9.80%) AP, seven (13.72%) chronic pancreatitis (CP)]. PHPT with AP (PHPT-AP) was more common among males with the presentation at a younger age (35.20 ± 16.11 vs 49.23 ± 14.80 years, P = 0.05) and lower plasma intact parathyroid hormone (iPTH) levels [125 (80.55-178.65) vs 519.80 (149-1649.55, P = 0.01)] compared to PHPT without pancreatitis (PHPT-NP). The mean serum calcium levels were similar in both PHPT-AP and PHPT-NP groups [(11.66 ± 1.15 mg/dL) vs (12.46 ± 1.71 mg/dL), P = 0.32]. PHPT-AP also presented with more gastrointestinal symptoms like abdominal pain, nausea, and vomiting with lesser skeletal and renal manifestations as compared to patients with PHPT-NP.

CONCLUSION

AP can be the only presenting feature of PHPT. Normal or higher serum calcium levels during AP should always draw attention towards endocrine causes like PHPT.

Does Baseline PTH Influence Recovery of Bone Mineral Density, Trabecular Bone Score and Bone Turnover Markers? A Prospective Study Following Curative PArathyroidectomy in Primary Hyperparathyroidism

OBJECTIVE

This prospective study was carried out to assess trabecular bone score, bone mineral density (BMD), and bone biochemistry in Indian subjects with symptomatic primary hyperparathyroidism (PHPT), and to study the influence of baseline parathyroid hormone (PTH) on recovery of these parameters following curative surgery.

METHODS

This was a 2-year prospective study conducted at a tertiary care centre in southern India. Baseline assessment included demographic details, mode of presentation, bone mineral biochemistry, BMD, trabecular bone score (TBS), and bone turnover markers (BTMs). These parameters were reassessed at the end of the first and second years following curative parathyroid surgery.

RESULTS

Fifty-one subjects (32 men and 19 women) with PHPT who had undergone curative parathyroidectomy were included in this study. The mean (SD) age was 44.6 (13.7) years. The TBS, BTMs, and BMD at lumbar spine and forearm were significantly worse at baseline in subjects with higher baseline PTH (≥250 pg/mL) when compared to the group with lower baseline PTH (<250 pg/mL). At the end of 2 years, the difference between high versus low PTH groups (mean ± SD) persisted only for forearm BMD (0.638±0.093 versus 0.698±0.041 g/cm2; P =.01). However, on follow-up visits in the first and second year after curative parathyroidectomy, there was no significant difference in BTMs, BMD at the femoral neck, lumbar spine, and TBS between the 2 groups stratified by baseline PTH.

CONCLUSION

The BMD at the forearm remained significantly worse in individuals with high baseline PTH even at 2 years after surgery, while other parameters including TBS improved significantly from baseline.

ABBREVIATIONS

25(OH)D = 25-hydroxyvitamin D; BMD = bone mineral density; BMI = body mass index; BTMs = Bone turnover markers; CTX = C-terminal telopeptide of type 1 collagen; DXA = dual energy X-ray absorptiometry; P1NP = N-terminal propeptide of type 1 procollagen; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; TBS = trabecular bone score.

Pancreatitis and hyperparathyroidism: Still a rare association!

BACKGROUND

Among the multitudinous etiologies of pancreatitis, primary hyperparathyroidism (PHPT) is rarely associated with pancreatitis. However, the cause and effect relationship between the two still evokes controversy. We aimed to study and characterize the nature of pancreatic disease in PHPT.

METHODS

A retrospective single-center study was carried out in North India over a period of 1 year (June 2015 to May 2016). All patients with pancreatitis were included. In patients with high calcium levels, Intact Parathyroid Hormone (iPTH) by Radioimmunoassay (RIA) and an Technetium 99m Sestamibi scintigraphy (MIBI-Tc-99m) scan were performed.

RESULTS

During the study period, 70 patients with pancreatitis were admitted to our hospital (53 with acute pancreatitis [AP] and 17 with chronic pancreatitis [CP]). Of them, 5 patients (9.4%) were detected to have PHPT. The mean age of patients was 30.4 years (20-49 years) with 3 males and 2 females, including 1 pregnant female (29th week of gestation). Contrast enhanced computed tomography (CECT) abdomen was performed in 4 cases (excluding 1 pregnant patient) with mean Computed tomography severity index (CTSI) of 4.7 (2-8). Four patients were detected to have increased uptake in one of the parathyroid glands, and the fifth patient had an ectopic parathyroid uptake in the mediastinum. All the resected samples were identified as parathyroid adenoma on histology. The patients were followed up for 1 year with no reported recurrence of symptoms.

CONCLUSION

The data suggest an association between pancreatitis (both acute and chronic) and hypercalcemia due to PHPT. A high calcium value during AP or CP should always draw suspicion and warrants corresponding investigations in search of endocrine or malignant cause.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism

Background & objectives:

The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease.

Methods:

In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients.

Results:

A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P<0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P<0.05) and parathyroid hormone (PTH) (P<0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group.

Interpretation & conclusions:

Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

Primary Hyperparathyroidism and Pancreatitis: A Rare Association with Multiple Facets

Primary hyperparathyroidism (PHPT) is rarely associated with the occurrence of acute or chronic pancreatitis. Hypercalcemia plays a major role in the pathogenesis. We report five cases of pancreatitis revealing PHPT. Patients and Methods. This is a retrospective study of 4 years, including all patients admitted to intensive care unit or gastroenterology department, for an acute or chronic pancreatitis revealing primary hyperparathyroidism. Results. We included 5 patients, all female, with mean age 54 years [40-76 years]. The PHPT was in all cases revealed by acute pancreatitis (AP). This one was oedematous in four cases and severe in one case. It occurred twice in calcified chronic pancreatitis (CCP). There was hypercalcemia in all cases. The PHPT was associated with a high rate of parathyroid hormone in 4 cases. The secreting lesion was an adenoma in 5 cases. Two patients had in addition bilateral renal calcifications. The outcome was favorable in 4 patients among whom 3 have had parathyroid surgery. A death was noted by superinfection of necrosis in the case of severe AP. Conclusion. The occurrence of pancreatitis during hyperparathyroidism is rare. Normal or elevated calcemia during acute or chronic pancreatitis should always get attention.