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Hypoparathyroidism

Rare Hypoparathyroidism


Presentation

Hypoparathyroidism presents the following signs and symptoms:

Fatigue
  • Caucasian man with a history of chronic omeprazole use and periodic seizures, who presented to the emergency department of a secondary hospital in Southern Brazil with symptoms of major depression (sadness, anhedonia, loss of appetite, insomnia, and fatigue[ncbi.nlm.nih.gov]
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019[patientslikeme.com]
  • […] lead to the following hypoparathyroidism symptoms: A burning or tingling feeling (paresthesia) in the lips, toes, or fingertips Muscle twitching and spasms (tetany) that affect the mouth, throat, arms, and hands Seizures Brittle nails Patchy hair loss Fatigue[tgh.org]
  • Many also report a number of subjective symptoms such as fatigue, headaches, bone pain and insomnia. Crampy abdominal pain may occur.[en.wikipedia.org]
Stridor
  • After failing medical management, she underwent supraglottoplasty with improvement of stridor, but persistent apneic events. Further work-up showed severe hypocalcemia due to hypoparathyroidism.[ncbi.nlm.nih.gov]
  • Hypoparathyroidism has wide variety of presentations: from the asymptomatic patient with dramatically low serum calcium to the acutely symptomatic patient with neuromuscular irritability, tetany, painful muscle cramps, stridor, and even seizures with[bestpractice.bmj.com]
  • Stridor. Convulsions (usually grand mal). Syncope. Emotional lability, anxiety and depression, confusion. Memory impairment. Lethargy. Headaches. Brittle nails. Dry hair and skin. Painful menstruation.[patient.info]
  • Severe hypocalcemia presents with seizures, stridor, prolonged QTc, and tetany. Electrocardiogram (ECG) findings in severe hypocalcemia. Pathophysiology Mature PTH is an 84–amino acid protein.[emedicine.com]
Dyspnea
  • A 40-year-old woman with no prior history of thyroid disease presented with a six month history of progressive thyroid enlargement complicated by worsening dysphagia and positional dyspnea.[ncbi.nlm.nih.gov]
  • Hoarseness or voice changes, wheezing and difficulty breathing (dyspnea) can also be associated with chronic hypoparathyroidism. Sudden, muscular spasms affecting the larynx (laryngospasm) and the bronchial tubes (bronchospasm) may also occur.[rarediseases.org]
Abdominal Pain
  • A 73-year-old man with metastatic melanoma presented to the Emergency Department for the chief complaints of imbalance, general muscle weakness, abdominal pain and tingling in extremities.[ncbi.nlm.nih.gov]
  • Signs and symptoms include muscle cramps, abdominal pain, dry skin, brittle nails, cataracts, tetany, and convulsions Condition produced by greatly reduced function of the parathyroids possibly due to autoimmune disease or genetic factors, or by the removal[icd9data.com]
  • Symptoms may include any of the following: Abdominal pain Brittle nails Cataracts Calcium deposits in some tissues Decreased consciousness Dry hair Dry, scaly skin Muscle cramps Muscle spasms called tetany (can affect the larynx, causing breathing difficulties[nlm.nih.gov]
  • Hypoparathyroidism symptoms Call your primary care physician if you notice any of the following symptoms of hypoparathyroidism: Brittle nails and hair Tingling in the toes, fingers and lips Abdominal pain Cataracts Dry skin Muscle spasms called tetany[rush.edu]
Diarrhea
  • My guess would be that the Ca was not giving her diarrhea but that she was malabsorbing the Ca due to diarrhea and rapid GI transit. Therefore if she still has significant diarrhea, I would recommend an evaluation for it.[endotext.org]
  • As soon as there is improvement in the patient's clinical condition, it is necessary to begin the treatment of comorbidities increasing the risk of renal failure or alkalosis (i.e. vomiting, diarrhea).[ncbi.nlm.nih.gov]
  • Taking lots of one type often will give a patient problems with their GI tract (diarrhea, or more commonly, constipation).[parathyroid.com]
  • Other causes of hypomagnesemia include malnutrition, malabsorption, diabetes, chronic diarrhea, certain kidney disorders, and the use of certain medications.[rarediseases.org]
Abdominal Cramps
  • At presentation, he had ataxia, paresthesia in the hands and feet, and abdominal cramping. Magnetic resonance imaging of the brain was unremarkable. He was found to be hypocalcemic with undetectable plasma parathyroid hormone.[ncbi.nlm.nih.gov]
Blurred Vision
  • If symptoms do develop, they may include: Weakness Muscle crampsor twitching Pain Difficulty with walking Tingling around the mouth, fingers, and toes Excessive nervousness Loss of memory Mood swings Anxiety Blurred vision due to cataracts Thin, brittle[uvahealth.com]
Muscle Cramp
  • Symptoms of the disease result from increased neuromuscular irritability caused by hypocalcaemia and include tingling, muscle cramps and seizures.[ncbi.nlm.nih.gov]
  • Signs and symptoms include muscle cramps, abdominal pain, dry skin, brittle nails, cataracts, tetany, and convulsions Condition produced by greatly reduced function of the parathyroids possibly due to autoimmune disease or genetic factors, or by the removal[icd9data.com]
  • Hypoparathyroidism presents the following signs and symptoms: Pain in the abdomen Cataract Muscle cramps and carpopedal spasms Weakening of tooth enamel Painful menstrual cycle Seizures Tingling sensation in the hands, fingers and feet Brittle nails Dry[symptoma.com]
  • Symptoms of hypoparathyroidism may include tingling in the lips, fingers, and toes; dry hair, brittle nails, and dry, coarse skin; muscle cramps and pain in the face, hands, legs, and feet ; cataracts ; dental problems; memory loss, headaches, and muscle[medicinenet.com]
Chvostek Sign
  • The following are signs of hypocalcemia: Chvostek's sign (watch video) is the twitching of the facial muscles in response to tapping over the area of the facial nerve.[smartypance.com]
  • KNOW how to elicit a positive Chvostek’s Sign (nerve hyperexcitability of the facial nerves).[registerednursern.com]
  • sign : hypocalcemia hyperexcitable nerves tapping the facial nerve on the cheek contraction of facial muscles Trousseau sign : inflate BP cuff allow for occlusion of brachial artery for a few minutes carpal spasm Chronic manifestations Extrapyramidal[amboss.com]
  • Physical examination of someone with hypocalcemia may show tetany, but it is also possible to provoke tetany of the facial muscles by tapping on the facial nerve (a phenomenon known as Chvostek's sign) or by using the cuff of a sphygmomanometer to temporarily[en.wikipedia.org]
  • (OH)2-vitamin levels decrease Prognosis no current hormone replacement therapy available treatment is aimed at supplementing vitamin D and calcium levels Presentation Symptoms hypocalcemia more common in hypoparathyroidism neuromuscular irritability Chvostek's[orthobullets.com]
Carpopedal Spasm
  • Trousseau's sign (watch video) is carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes.[smartypance.com]
  • It results in hypocalcemia. tetany: peripheral paresthaesia, carpopedal spasm, seizures emotional lability, depression and anxiety, psychosis short stature There are a number of causes of hypoparathyroidism 1 : iatrogenic, e.g. post parathyroidectomy[radiopaedia.org]
  • spasm Type 1 Excludes hysterical tetany ( F44.5 ) neonatal tetany ( P71.3 ) parathyroid tetany ( E20.9 ) post-thyroidectomy tetany ( E89.2 ) Cataract (cortical) (immature) (incipient) H26.9 ICD-10-CM Diagnosis Code H26.9 Unspecified cataract 2016 2017[icd10data.com]
  • Carpopedal spasm is induced. Raised intracranial pressure with papilloedema. Cataracts. Dental abnormalities and enamel dysplasia. Brittle nails with transverse grooves. Dry, rough skin. Hyperreflexia.[patient.info]
  • Hypoparathyroidism presents the following signs and symptoms: Pain in the abdomen Cataract Muscle cramps and carpopedal spasms Weakening of tooth enamel Painful menstrual cycle Seizures Tingling sensation in the hands, fingers and feet Brittle nails Dry[symptoma.com]
Trousseau Sign
  • Trousseau's sign (watch video) is carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes.[smartypance.com]
  • Positive Trousseau’s Sign D. Tingling and numbness of lips and fingers E. Calcium level of 15 mg/dL F. Phosphate level 1.2 G. Renal calculi 11. This medication is used to treat hyperparathyroidism in patients with chronic renal failure.[registerednursern.com]
  • sign : inflate BP cuff allow for occlusion of brachial artery for a few minutes carpal spasm Chronic manifestations Extrapyramidal disorders : symptoms include parkinsonism, dystonia, hemiballismus, choreoathetosis, oculogyric crises, or dementia Ocular[amboss.com]
  • sign of latent tetany).A number of medical emergencies can arise in people with low calcium levels.[en.wikipedia.org]
Muscle Twitch
  • Abnormal blood calcium and phosphorus levels can lead to the following hypoparathyroidism symptoms: A burning or tingling feeling (paresthesia) in the lips, toes, or fingertips Muscle twitching and spasms (tetany) that affect the mouth, throat, arms,[tgh.org]
  • Patients with hypoparathyroidism can experience numbness, tingling, muscle twitching, spasms or cramps, abnormal heart rhythm, and seizures as a consequence of low blood calcium levels.[raredr.com]
  • If you've had surgery involving your thyroid or neck, watch for signs and symptoms that could indicate hypoparathyroidism, such as a tingling or burning sensation in your fingers, toes or lips, or muscle twitching or cramping.[mayoclinic.org]
Psychiatric Manifestation
  • The definitive diagnosis was primary hypoparathyroidism with psychiatric manifestations due to chronic hypomagnesemia induced by proton pump inhibitor use.[ncbi.nlm.nih.gov]
  • Urita, Characteristics of 22q 11.2 deletion syndrome undiagnosed until adulthood: an example suggesting the importance of psychiatric manifestations, Case Reports, 2015, jun08 1, (bcr2014208903), (2015). M. Zohair Rahman and Aliya A.[doi.org]
Anhedonia
  • The patient was a 22-year-old Caucasian man with a history of chronic omeprazole use and periodic seizures, who presented to the emergency department of a secondary hospital in Southern Brazil with symptoms of major depression (sadness, anhedonia, loss[ncbi.nlm.nih.gov]
Seizure
  • CONCLUSION: Thus, AED treatment cannot improve the seizure outcomes in children with parathyroid disorder, even in such cases as suspected structural seizure caused by subcortical calcifications.[ncbi.nlm.nih.gov]
  • Seizures or breathing problems are an emergency. Call 911 or your local emergency number right away. Parathyroid-related hypocalcemia Clarke BL, Brown EM, Collins MT, et al. Epidemiology and diagnosis of hypoparathyroidism.[nlm.nih.gov]
Paresthesia
  • The clinical manifestations of primary hypoparathyroidism include tetany, seizures, paresthesias, dementia, and parkinsonism.[ncbi.nlm.nih.gov]
  • Symptoms Signs and symptoms of hypoparathyroidism can include: Tingling or burning (paresthesia) in your fingertips, toes and lips Muscle aches or cramps in your legs, feet, abdomen or face Twitching or spasms of your muscles, particularly around your[mayoclinic.org]
Irritability
  • Symptoms of the disease result from increased neuromuscular irritability caused by hypocalcaemia and include tingling, muscle cramps and seizures.[ncbi.nlm.nih.gov]
  • Hypoparathyroidism has wide variety of presentations: from the asymptomatic patient with dramatically low serum calcium to the acutely symptomatic patient with neuromuscular irritability, tetany, painful muscle cramps, stridor, and even seizures with[bestpractice.bmj.com]
  • Symptoms include tetany, irritability, and muscle weakness.[medical-dictionary.thefreedictionary.com]
  • Generally, a central venous catheter is recommended, as the calcium can irritate peripheral veins and cause phlebitis.[en.wikipedia.org]
Lethargy
  • High calcium Early warning signs include: extreme tiredness and lethargy; feeling weak; constipation mild confusion If left untreated, symptoms can include: feeling and being sick; drowsiness; passing large amounts of urine; feeling very thirsty; dehydration[home.bt.com]
  • Lethargy. Headaches. Brittle nails. Dry hair and skin. Painful menstruation. Important points to elicit in the history include: History of previous neck surgery. Family history of any hypoparathyroid disorders.[patient.info]
Hyperreflexia
  • Hyperreflexia. Other symptoms and signs depend on the aetiology: DiGeorge's syndrome : Recurrent infections due to T-cell immunodeficiency. Congenital heart disease and its related symptoms, heart murmur. Speech delay.[patient.info]

Workup

A complete physical examination should be done in order to study the signs of hypoparathyroidism. A blood work would reveal levels of calcium, phosphorus, magnesium and PTH. Urine test is done to see whether the body is excreting excessive amount of calcium through urine. For diagnosing hypoparathyroidism in children, it is necessary to check for signs of appropriate teeth and mental development.

Calcium Decreased
  • Lab work reveals a decreased serum calcium, decreased parathyroid hormone, and an elevated serum phosphate. On EKG there is a prolongation of the QT interval. Hypoparathyroidism will present with a decreased parathyroid hormone ( PTH).[smartypance.com]
  • Results also indicated that serum calcium remained stable and 24-hour urinary calcium decreased by 32%. Elevation of serum calcium above the upper limit of normal was only reported in 5% of all measurements.[endocrinologyadvisor.com]
Normocytic Normochromic Anemia
  • From laboratory examination, there was slight normocytic normochromic anemia (Hb: 10.7 gr/dL), normal fT4: 1.21 ng/dL (0.7-1.48 ng/dL), slightly low Calcium: 8.3 mg/dL (8.5-10.2 mg/dL), others were within normal limit but there was no Phosphorus level[ncbi.nlm.nih.gov]
Prolonged QT Interval
  • QT interval Serum Ca Serum Phos PTH Common Cause Hyperparathyroidism adenoma Hypoparathyroidism thyroidectomy (including parathyroid) Ectopic PTH malignancy Vit D malabsorption celiac disease, other GI disease hypo vit D with no phosphate excretion from[orthobullets.com]
  • Other possible investigations: ECG: prolonged QT interval which may progress to ventricular fibrillation or heart block. Echocardiogram: cardiac abnormalities (in DiGeorge's syndrome). Renal ultrasound: looking for renal calculi.[patient.info]

Treatment

Treatment of hypoparathyroidism is directed towards normalizing the levels of calcium and phosphorus and controlling the symptoms. Combination of drug therapy and modifications in dietary regime can help in better management of the disease condition. The following are methods employed for treating hypoparathyroidism:

  • Drugs to increase calcium and vitamin D levels in the body [8].
  • A diet rich in calcium is advised. In addition, individuals are also advised to avoid foods rich in phosphorus.
  • In case the patient is experiencing serious symptoms, an immediate administration of calcium via the intravenous route is suggested.

Prognosis

If the disease is diagnosed on time and treatment initiated then the prognosis is usually good. However, if the condition has adversely affected the bones, eyes and brain calcification then these can seldom be treated.

Complications

Several complications can set in as a result of poor management of hypoparathyroidism. These include the following conditions:

  • If children are affected then they can suffer from poor mental development, delayed growth and abnormal teeth formation.
  • Deposition of calcium in the brain.

These were some of the irreversible complications of hypoparathyroidism. Some of the reversible complications that can be managed well with appropriate treatment regime include:

Etiology

Hypoparathyroidism is a result of insufficient production of PTH which occurs due to the following factors:

  • Acquired hypoparathyroidism is a condition wherein an injury to the gland is the major cause of PTH deficiency. In addition, surgical procedures to remove the glands (total thyroidectomy) as part of the treatment procedure for certain disease conditions also induce development of hypoparathyroidism [1]. 
  • Hypoparathyroidism is also caused due to an autoimmune disease condition (e.g. autoimmune hypoparathyroidism) in which the body regards the glands as foreign bodies and sets out antibodies to destroy them [2]. As a result, the glands do not produce the hormone.
  • Congenital hypoplasia of the parathyroid gland like Di George syndrome is a disorder affecting only children wherein the parathyroid glands are absent which results in hypoparathyroidism. It is a heredity condition, wherein the parathyroid glands are either absent from birth or they do not produce sufficient PTH [3].
  • Cancer treatment of the face and neck causes extensive exposure to radiations and chemotherapy that leads to destruction of the parathyroid glands.
  • Insufficient serum magnesium levels are yet another factor for development of hypoparathyroidism. Under normal circumstances optimal levels of magnesium are required for the parathyroid glands to produce PTH. When there are low levels of magnesium in the blood, the gland fails to produce sufficient hormones.
  • Familial hypoparathyroidism occurs as a secondary condition to other endocrine disorders. 

Epidemiology

Hypoparathyroidism is an uncommon condition and is considered to be a rare disease as stated by the Office of Rare Diseases (ORD) of the National Institutes of Health (NIH). It has been estimated that less than 200,000 individuals in the US are affected by this rare disease condition.

The age of onset completely depends on the causative factor. In the United States, approximately 7.6% of those who undergone thyroidectomy surgery will result in hypoparathyroidism [4].

Sex distribution
Age distribution

Pathophysiology

PTH is important for the regulation of the minerals namely calcium and phosphorus. It also helps in maintaining the vitamin D levels in the bone. Therefore, insufficient levels of PTH would severely affect the calcium–phosphorus balance. In order to maintain appropriate serum calcium levels, it is necessary that fluctuations of the calcium levels in the intestinal tract, bones and kidney be properly regulated.

Hypocalcemia in hypoparathyroidism causes signs and symptoms of neuromuscular irritability [5]. Calcium along with PTH and vitamin D3 are involved in calcium regulation. The progressive deficiency in calcium and vitamin D3 in the serum will result in an increase in the volume of cancellous bones and an increase in the trabecular width in flat bones making them more brittle [6].

In addition, PTH also plays a vital role in regulation of distal renal tubular calcium reabsorption. Low concentration of serum calcium stimulates PTH secretion; whereas phosphate reabsorption mechanism is also regulated by PTH. Therefore, any imbalance in the PTH levels grossly affects the serum phosphate and calcium levels.

Prevention

So far, no preventive steps have been designed to avoid hypoparathyroidism. However, if individuals are undergoing neck surgery, then they should discuss with the surgeon and take necessary precautions in order to avoid any damage to the parathyroid gland.

Surgeons and endocrinologists must work hand in hand during the surgical removal of the thyroid gland to reduce incidence and complications of hypoparathyroidism [9]. A good surgical technique is paramount during the performance of total thyroidectomy and the autotransplatation of PTH gland during its inadvertent removal is as important in its prevention [10].

Summary

Hypoparathyroidism is a condition characterized by low levels of parathyroid hormone (PTH). In this condition, the parathyroid glands fail to produce optimal levels of PTH causing its deficiency. PTH is known to play a vital role in maintaining the levels of two minerals namely calcium and phosphorus.

A deficiency of PTH would thus disrupt the mineral balance and cause low levels of ionized calcium in blood and bones and high serum phosphorus levels. It is an uncommon condition and gets corrected through an appropriate treatment plan.

Patient Information

Definition

Hypoparathyroidism is an uncommon condition characterized by low levels of parathyroid hormone. It occurs as a result of injury or damage to the parathyroid glands.

Cause

Injury to the neck and thyroid during surgical procedures may lead to the development of hypoparathyroidism. In rare cases, this disorder occurs as a secondary condition to radioactive iodine treatment for hyperthyroidism or is inherited.

Symptoms

Symptoms of hypoparathyroidism include abdominal pain, tingling sensation in the hands and legs, stunted growth, calcification in the brain, muscle cramps, dry hair, dry scalp, improper development of tooth enamel in children, cataracts, brittle nails and seizures.

Diagnosis

Diagnosis of this condition consists of careful examination of the symptoms and blood work to assess the calcium and phosphorus levels. Urine test to determine the levels of calcium excreted through urine is also done.

Treatment

Treatment is geared towards administration of oral supplements to normalize the calcium and vitamin D levels. Consuming diet rich in calcium and low in phosphorus is advised.

References

Article

  1. Ebrahimi H, Edhouse P, Lundgren CI, et al. Does autoimmune thyroid disease affect parathyroid autotransplantation and survival? ANZ J Surg. May 2009; 79(5):383-5.
  2. Brown EM. Anti-parathyroid and anti-calcium sensing receptor antibodies in autoimmune hypoparathyroidism. Endocrinol Metab Clin North Am. Jun 2009; 38(2):437-45,
  3. Goltzman D, Cole DEC. Hypoparathyroidism. In: Favus MJ, ed. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Philadelphia, Pa: Lippincott-Raven; 1996:220-3.
  4. Powers J, Joy K, Ruscio A, Lagast H. Prevalence and incidence of hypoparathyroidism in the United States using a large claims database. J Bone Miner Res. 2013; 28(12):2570-6 (ISSN: 1523-4681)
  5. Bhadada SK, Bhansali A, Upreti V, Subbiah S, Khandelwal N. Spectrum of neurological manifestations of idiopathic hypoparathyroidism and pseudohypoparathyroidism. Neurol India. Jul-Aug 2011; 59(4):586-9.
  6. Rubin MR, Dempster DW, Zhou H, et al. Dynamic and structural properties of the skeleton in hypoparathyroidism. J Bone Miner Res. Dec 2008; 23(12):2018-24.
  7. Pesić M, Radojković D, Radenković S, Spasić M, Lukić S. Epileptic seizure as the first sign of hypoparathyroidism. Vojnosanit Pregl. 2011; 68(1):81-4 (ISSN: 0042-8450)
  8. Cheung M. Drugs used in paediatric bone and calcium disorders. Endocr Dev. 2009; 16:218-232.
  9. Khan MI, Waguespack SG, Hu MI. Medical management of postsurgical hypoparathyroidism. Endocr Pract. 2011; 17 Suppl 1:18-25 (ISSN: 1934-2403)
  10. Paek SH, Lee YM, Min SY, Kim SW, Chung KW, Youn YK. Risk factors of hypoparathyroidism following total thyroidectomy for thyroid cancer. World J Surg. 2013; 37(1):94-101 (ISSN: 1432-2323)

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Last updated: 2019-07-11 21:25