Parathyroid Disease

Myopathies of endocrine origin: A review for physicians

Myopathies are a common manifestation of endocrine disorders. Endocrine myopathies are often overlooked while considering differential diagnoses in patients with musculoskeletal symptoms. The hindrance to mobility and the musculoskeletal discomfort owing to these myopathies are important causes of disability and depreciated quality of life in these patients. Endocrine myopathies occur due to the effects of endogenous or iatrogenic hormonal imbalance on skeletal muscle protein and glucose metabolism, disrupting the excitation-contraction coupling. Abnormalities of the pituitary, thyroid, parathyroid, adrenal, and gonadal hormones have all been associated with myopathies and musculoskeletal symptoms. Endocrine myopathies can either be the complication of a secondary endocrine disorder or a presenting symptom of a missed underlying disorder. Therefore, an underlying endocrine abnormality must always be excluded in all patients with musculoskeletal symptoms. This review presents a compilation of various endocrine myopathies, their etiopathogenesis, clinical presentation, diagnostic modalities, and treatment protocols.

Hypoparathyroidism: Musculoskeletal Manifestations Related to Parathormone Deficiency

BACKGROUND

Hypoparathyroidism is a rare metabolic disorder that can be responsible for musculoskeletal manifestations.

AIM

We present a systematic review of musculoskeletal manifestations of adult-onset nonsurgical nongenetic hypoparathyroidism.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the MEDLINE database, including manuscripts describing musculoskeletal manifestations of adult-onset nonsurgical nongenetic hypoparathyroidism.

RESULTS

Musculoskeletal manifestations included myopathy, shoulder disorder, immune-negative non-erosive peripheral arthritis, axial involvement simulating spondylarthritis, and diffuse ligamentous ossifications. An association between hypoparathyroidism and spondyloarthritis or autoimmune diseases is possible. T-cell activation, seen in patients with hypoparathyroidism, may explain the co-occurrence of hypoparathyroidism with other autoimmune diseases. The treatment of these manifestations is based on calcium and active vitamin D supplementation. Parathyroid hormone may have an anabolic effect on muscle atrophy and muscle weakness. Parathyroid hormone can also promote bone formation and bone resorption by stimulating osteoclast differentiation by increasing RANKL (receptor activator for nuclear factor kappa-B ligand) expression. Therefore, hypoparathyroidism can be responsible for an increase in bone mineral density. However, the risk of fractures does not appear to be reduced due to changes in bone microarchitecture and the high risk of falls. Treatment with parathyroid hormone has been shown to improve bone microarchitecture.

CONCLUSION

Our review showed that musculoskeletal manifestations are frequent in patients with hypoparathyroidism, including muscular, axial, peripheral articular, and entheseal manifestations.

Brittle Bone Imaging: Diagnostic Procedures in Adults

This article concentrates on generalized disorders causing bone fragility. The most frequent cause of brittle bone disease is osteoporosis, only diagnosed by elimination. First, malignant osteopathy must be ruled out: fracture on metastasis or multiple myeloma, which mimics osteoporosis when presenting as diffuse demineralization. Second, patients should be screened for signs of hyperparathyroidism or osteomalacia. Much more rarely, many other pathologies can lead to brittle bone by demineralization or associated increased bone density.The radiologist needs to know the clinical context and notably the patient's age (childhood or adulthood) at discovery, and known pathologies and ongoing or previous treatments: corticotherapy, bisphosphonates, denosumab, or prior radiotherapy in the affected region. Diagnostic hypotheses are guided by the type of demineralization and the presence of lytic, mixed, or densifying areas. Lastly, the aspect and location of fractures and association with other bone abnormalities refine the diagnosis.

Trivial Indirect Trauma Causing Recurrent Bilateral Quadriceps Tendon Rupture in End Stage Renal Failure Patient: A Case Report

Recurrent bilateral quadriceps tendon rupture in a young patient is a very rare incident. The underlying medical condition is always present and may have contributed to this injury. We report a recurrent bilateral quadricep tendon rupture in a 28-year-old man with underlying end-stage renal failure that occurred 10 months after the first repair. Injuries were indirect and trivial during the first and second events. Surgical repair was performed with similar technique for both incidents and he was advised to exercise extreme cautions after the second repair. He could return to his daily activities with no further recurrence at 30 months follow-up.

Parathyroid cysts: the Latin-American experience

BACKGROUND

Parathyroid cyst is an infrequent and unsuspected disease. There are more than 300 hundred cases reported in the world literature, a few of them are from Latin America. The experience of our centers and a review of the cases are presented.

METHODS

Case report of a series of patients with parathyroid cyst from our institutions according to the CARE guidelines (Case Reports). A search of Medline, Embase, BIREME (Biblioteca Regional de Medicina) LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), Google Scholar and Scielo (Scientific Electronic Library on Line) databases and telephonic or email communications with other experts from Latin-America was performed .

RESULTS

Six patients with parathyroid cyst were found in our centers in Colombia. Most of them were managed with aspiration of the cyst. Two of them required surgery. Only one case was functional. Twelve reports from Latin America were found for a total of 18 cases in our region adding ours.

CONCLUSIONS

Parathyroid cysts are uncommonly reported in Latin America. Most of them are diagnosed postoperatively. Suspicion for parathyroid cyst should be raised when a crystal clear fluid is aspirated from a cyst. The confirmation of the diagnosis may be easily done if parathyroid hormone (PTH) level is measured in the cyst fluid.

Prevalence and incidence of hypoparathyroidism in the United States using a large claims database

Hypoparathyroidism is a rare endocrine disorder whose incidence and prevalence have not been well defined. This study aimed to 1) estimate the number of insured adult patients with hypoparathyroidism in the United States and 2) obtain physician assessment of disease severity and chronicity. Prevalence was estimated through calculation of diagnoses of hypoparathyroidism in a large proprietary health plan claims database over a 12-month period from October 2007 through September 2008 and projected to the US insured population. Incidence was also calculated from the same database by determining the proportion of total neck surgeries resulting in either transient (≤6 months) or chronic (>6 months) hypoparathyroidism. A physician primary market research study was conducted to assess disease severity and determine the percentage of new nonsurgical patients with hypoparathyroidism. Incidence data were entered into an epidemiologic model to derive an estimate of prevalence. The diagnosis-based prevalence approach estimated 58,793 insured patients with chronic hypoparathyroidism in the United States. The surgical-based incidence approach yielded 117,342 relevant surgeries resulting in 8901 cases over 12 months. Overall, 7.6% of surgeries resulted in hypoparathyroidism (75% transient, 25% chronic). The prevalence of chronic hypoparathyroidism among insured patients included in the surgical database was estimated to be 58,625. The physician survey found that 75% of cases treated over the past 12 months were reported due to surgery and, among all thyroidectomies and parathyroidectomies and neck dissections performed in a year, 26% resulted in transient hypoparathyroidism and 5% progressed to a chronic state. In conclusion, the two claims-based methods yielded similar estimates of the number of insured patients with chronic hypoparathyroidism in the United States (~58,700). The physician survey was consistent with those calculations and confirmed the burden imposed by hypoparathyroidism.

[Parathyroid dysfunction and rheumatic manifestations]

Parathyroid dysfunction, leading to severe clinical symptoms and radiographic changes, has decreased over the last years due to routine laboratory checks including serum calcium levels. Thus, abnormal calcium levels are detected early in the course of the disease and the underlying cause treated accordingly. Hyperparathyroidism often leads to osteoporosis and low-trauma fractures. When evaluating secondary osteoporosis analysis of calcium, phosphate and intact parathyroid hormone levels are mandatory. Osteitis fibrosa cystica and brown tumors are less frequent findings of hyperparathyroidism. However, in patients with arthritis or bone symptoms, hyperparathyroidism has to be evaluated as a possible reason. Other manifestations of hyperparathyroidism include myopathy, tendon ruptures and unspecific symptoms of the muscles and skeleton. Gout as well as pseudogout may be associated with hyperparathyroidism. Hypoparathyroidism may cause musculoskeletal diseases mimicking ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Myopathies are sometimes induced by hypoparathyroidism. An association between systemic lupus erythematosus and hypoparathyroidism seems to exist.