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Case
 15 yr old, girl.
 Referred to Dr. Wade for LL deformity &
abnormal gait for the last 5 yrs
 Increasing with time, associated with generalized
bone pain.
 V/S stable … Afebrile.
 CBC: N RP: N Ca: 3,39
 Al. Ph.: 300 PTH: 1092
Overview
 Parathyroid glands function
 Maintain serum calcium concentrations
 Regulate bone metabolism.
 PTH secretion stimulated by a fall in the
extracellular calcium concentration
 Hydroxylation of 25-hydroxy-vitamin D at the
proximal convoluted tubule in the kidney
 Increases renal & GI calcium reabsorption.
 Increases bone resorption through stimulation of
osteoclast-activating factors from osteoblasts.
Overview
 Calcium
 At parathyroid gland, Binds to the calcium receptor
 PTH secretion and parathyroid cell growth are
inhibited.
 At the kidney, inhibits the 1-hydroxylation of 25-
hydroxy-vitamin D.
 At thyroid C cells, stimulating calcitonin release 
regulate bone resorption.
Classification
 Primary hyperparathyroidism
 Oversecretion of PTH due to gland pathology.
 Secondary hyperparathyroidism
 Reaction of the parathyroid glands to a hypocalcaemia
caused by something other than a parathyroid
pathology, e.g. chronic renal failure.
 Tertiary hyperparathyroidism
 Hyperplasia of the parathyroid glands and a loss of
response to serum calcium levels.
 Seen in patients with chronic renal failure and is an
autonomous activity.
PTH
Serum Ca
Type
H
H
Primary
H
L / N
Secondary
H/O chronic kidney
failure & 2ry
H
H
Tertiary
Radiological Findings
 Plain-film radiography has limited diagnostic
value, especially in the early stages of the disease.
 Normal findings do not rule out
hyperparathyroidism.
 Most of findings on radiographs are not specific.
Radiological Findings (1)
 Osteopenia is one of the most common findings
 Fine trabeculations are initially lost, ended with
ground appearance in the trabeculae.
Radiological Findings (2)
 Bone resorption:
 Subperiosteal
 Intracortical
 Trabecular
 Endosteal
 Subchondral
 Subligmentous
 Subtendouns
Subperiosteal Bone Resorption
 An early and pathognomonic sign.
 Can affect many sites, the most common site is
the middle phalanges of the index and middle
fingers, on the radial aspect.
Intracortical Bone Resorption
 Indicator of rapid bone turn over.
Trabecular Bone Resorption
 Usually seen in advanced disease.
Endosteal Bone Resorption
 Medullary cavity widens with thinning of the
inner cortex.
Subchondral Bone Resorption
 Most common in the joints of the axial skeleton.
Subligamentous & Subtendinous
Bone Resorption
 At insertion sites on bones.
Radiological Findings (3)
 Rugger-jersey spine.
 Ill-defined bands of increased bone density
adjacent to the vertebral endplates
 More common in secondary disease
Radiological Findings (4)
 Brown tumors
 Well-circumscribed lytic lesions of bone that
represent the osteoclastic resorption of an area of
bone with fibrous replacement.
 Consist of fibrous tissue, woven bone and supporting
vasculature, but no matrix.
 Single or multiple, present in any site, usually
occur in cortical bone.
 Become sclerotic on radiographs.
Radiological Findings (5)
 Abnormal calcification
 Chondrocalcinosis
 Vascular calcification
 Calcified pulmonary nodules
 Cerebral subcortical calcification
 Calcification within the eyes
 Layering of soft-tissue calcification
 Cardiac calcifications
 Breast calcifications
 Renal calcification
 Hepatic calcification
Take Home Massage
 Elevated serum Ca levels & PTH levels, diagnosis
of primary hyperparathyroidism is certain.
 Radiologic features of primary
hyperparathyroidism are similar to secondary
form of the disease.
 The most common radiologic finding in primary
hyperparathyroidism is osteopenia
 Radiographic findings of subperiosteal resorption
should prompt consideration of the primary
hyperparathyroidism
Plain Radiological findings of Primary Hyperparathyrodism.pptx

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Plain Radiological findings of Primary Hyperparathyrodism.pptx

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  • 2. Case  15 yr old, girl.  Referred to Dr. Wade for LL deformity & abnormal gait for the last 5 yrs  Increasing with time, associated with generalized bone pain.  V/S stable … Afebrile.  CBC: N RP: N Ca: 3,39  Al. Ph.: 300 PTH: 1092
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  • 6. Overview  Parathyroid glands function  Maintain serum calcium concentrations  Regulate bone metabolism.  PTH secretion stimulated by a fall in the extracellular calcium concentration  Hydroxylation of 25-hydroxy-vitamin D at the proximal convoluted tubule in the kidney  Increases renal & GI calcium reabsorption.  Increases bone resorption through stimulation of osteoclast-activating factors from osteoblasts.
  • 7. Overview  Calcium  At parathyroid gland, Binds to the calcium receptor  PTH secretion and parathyroid cell growth are inhibited.  At the kidney, inhibits the 1-hydroxylation of 25- hydroxy-vitamin D.  At thyroid C cells, stimulating calcitonin release  regulate bone resorption.
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  • 9. Classification  Primary hyperparathyroidism  Oversecretion of PTH due to gland pathology.  Secondary hyperparathyroidism  Reaction of the parathyroid glands to a hypocalcaemia caused by something other than a parathyroid pathology, e.g. chronic renal failure.  Tertiary hyperparathyroidism  Hyperplasia of the parathyroid glands and a loss of response to serum calcium levels.  Seen in patients with chronic renal failure and is an autonomous activity.
  • 10. PTH Serum Ca Type H H Primary H L / N Secondary H/O chronic kidney failure & 2ry H H Tertiary
  • 11. Radiological Findings  Plain-film radiography has limited diagnostic value, especially in the early stages of the disease.  Normal findings do not rule out hyperparathyroidism.  Most of findings on radiographs are not specific.
  • 12. Radiological Findings (1)  Osteopenia is one of the most common findings  Fine trabeculations are initially lost, ended with ground appearance in the trabeculae.
  • 13. Radiological Findings (2)  Bone resorption:  Subperiosteal  Intracortical  Trabecular  Endosteal  Subchondral  Subligmentous  Subtendouns
  • 14. Subperiosteal Bone Resorption  An early and pathognomonic sign.  Can affect many sites, the most common site is the middle phalanges of the index and middle fingers, on the radial aspect.
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  • 19. Intracortical Bone Resorption  Indicator of rapid bone turn over.
  • 20. Trabecular Bone Resorption  Usually seen in advanced disease.
  • 21. Endosteal Bone Resorption  Medullary cavity widens with thinning of the inner cortex.
  • 22. Subchondral Bone Resorption  Most common in the joints of the axial skeleton.
  • 23. Subligamentous & Subtendinous Bone Resorption  At insertion sites on bones.
  • 24. Radiological Findings (3)  Rugger-jersey spine.  Ill-defined bands of increased bone density adjacent to the vertebral endplates  More common in secondary disease
  • 25. Radiological Findings (4)  Brown tumors  Well-circumscribed lytic lesions of bone that represent the osteoclastic resorption of an area of bone with fibrous replacement.  Consist of fibrous tissue, woven bone and supporting vasculature, but no matrix.  Single or multiple, present in any site, usually occur in cortical bone.  Become sclerotic on radiographs.
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  • 31. Radiological Findings (5)  Abnormal calcification  Chondrocalcinosis  Vascular calcification  Calcified pulmonary nodules  Cerebral subcortical calcification  Calcification within the eyes  Layering of soft-tissue calcification  Cardiac calcifications  Breast calcifications  Renal calcification  Hepatic calcification
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  • 33. Take Home Massage  Elevated serum Ca levels & PTH levels, diagnosis of primary hyperparathyroidism is certain.  Radiologic features of primary hyperparathyroidism are similar to secondary form of the disease.  The most common radiologic finding in primary hyperparathyroidism is osteopenia  Radiographic findings of subperiosteal resorption should prompt consideration of the primary hyperparathyroidism

Notas del editor

  1. Severe osteopenia may be complicated by pathologic fractures. Radiograph of the proximal tibia and fibula. Diffuse demineralization attributed to trabecular resorption is the most common plain radiographic sign of primary hyperparathyroidism
  2. Anteroposterior radiographic view of the right hand in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism (same patient as in Image 2). This image shows subperiosteal bone resorption along the radial aspects of the middle phalanges (arrows).
  3. Bilateral anteroposterior (AP) radiographic views of the hands in a patient with multiple endocrine neoplasia syndrome type 1 (MEN 1) and primary hyperparathyroidism. These images show subperiosteal bone resorption along the radial aspects of the middle phalanges.
  4. Radiograph of the phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption
  5. Anteroposterior radiographic view of the left shoulder in external rotation in a patient with primary hyperparathyroidism. This image shows the healing stage of marked subperiosteal resorption (arrow) of the medial aspect of the proximal humerus.
  6. Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image depicts subperiosteal distal clavicular resorption (arrows). Radiograph of the shoulder in a patient with primary hyperparathyroidism. This image demonstrates distal clavicular resorption
  7. Radiograph of the middle phalanges in a patient with primary hyperparathyroidism. This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption (white arrows). Also, note the subperiosteal and intracortical resorption of the middle phalanges (black arrows).
  8. Anteroposterior radiographic view of the top of the calvarium in a patient with primary hyperparathyroidism. This image shows trabecular bone resorption that has resulted in the salt-and-pepper appearance of the calvarium.
  9. Radiograph of the femur in primary hyperparathyroidism (same patient as in Image 10). This image shows scalloped defects along the inner margin of the femoral cortex (arrows), which denote endosteal resorption.
  10. Anteroposterior radiographic view of the clavicles. This image shows symmetric subchondral bone resorption of the acromioclavicular joints. Distal clavicular resorption can be subperiosteal or subchondral, but this finding is not specific for primary hyperparathyroidism.
  11. Posteroanterior (PA) chest radiograph in a 60-year-old woman shows subligamentous bone resorption of the inferior surface of the lateral ends of the clavicles.
  12. Posteroanterior (PA) chest radiograph shows multiple expansile brown tumors in the medial border of the left scapula and in several of the ribs (black arrows). Also note subperiosteal bone resorption along one of the rib margins (white arrow).
  13. Radiograph of the humerus in a patient with primary hyperparathyroidism. This image depicts a brown tumor. Note the osseous expansion and lucency of the proximal humerus. Brown tumors can have varied appearances.
  14. Radiograph of the mid femoral diaphysis in a patient with primary hyperparathyroidism. This image depicts brown tumors. Note the eccentric (arrowheads) and central positions (arrow) of the lesions.
  15. Radiograph of the pelvis in a patient with primary hyperparathyroidism. Note the presence of brown tumors in the pelvis
  16. Radiograph in a 53-year-old woman with nutritional osteomalacia shows a brown tumor in the region of the tibial tuberosity (left) and healing of the lesion after vitamin D therapy (right). Also note improved mineralization of the bones.
  17. Radiograph of both hands of a 36-year-old woman receiving long-term hemodialysis shows subperiosteal bone resorption affecting the radial aspect of the middle phalanges of the fingers. Note the extensive digital arterial calcification.