Definition

Metabolic bone disease are disorders of bone strength,

caused by abnormalities of minerals (such as calcium
and phosphorus), vitamin D, bone mass or bone
structure.

Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London.

Bone Remodelling

Role of Parathyroid Hormone

Laycock, John. Integrated Endocrinology 1st Edition. 2014 Wiley-Blackwell. Oxford

Metabolism of Vitamin D

Laycock, John. Integrated Endocrinology 1st Edition. 2014 Wiley-Blackwell. Oxford

Role of Calcium
Extracellular calcium homeostasis is vital for the control of a range of
processes, including:
Regulation of voltage-gated ion channels in neurons and muscle
Mineralization and strengthening of bone
Facilitation of blood clotting
Abnormalities in calcium metabolism occur if there is dysregulation in:
Parathyroid hormone production
Vitamin D production
Renal dysfunction
Metabolic bone disease

Solomon Louis, Apley and Solomons Concise System of Orthopaedics and Trauma. 2014. Taylor and Francis Group
Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London.

Gut dysfunction and dietary deficiency of calcium, phosphate or

Etiology and Pathophysiology

Pathologies underlying hyperparathyroidism
Type of
hyperparathyroi
dism

Pathology

Primary

Autonomous production of excessive parathyroid hormone by an

adenoma of a single parathyroid gland (sporadic cases or as part
of genetic syndromes such as MEN type 1 and 2a)
Multiple parathyroid gland hyperplasia (sporadic cases or as part
of genetic syndromes such as MEN type 1 and 2a)

Secondary

Renal failure increasing serum phosphate concentration

Renal failure or vitamin D deficiency resulting in a deficiency in
activated vitamin D, which causes a compensatory increase in
parathyroid hormone production to maintain serum calcium
concentration (calcium concentration is usually low or normal)

Tertiary

Autonomous hypersecretion of parathyroid hormone in some

Shlorno, Melmed. Williams
of Endocrinology
13th Edition. 2016. Elsevier. Philadelphia
cases Textbook
of persistent
secondary
Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London.
hyperparathyroidism, which results in hypercalcaemia and often

Epidemiology
United States
Parathyroid cancer is a rare disease, occurring with an
annual incidence of approximately 1.25 cases per
10,000,000 persons.[2] It occurs in less than 1% of all
cases of hyperparathyroidism.
International
A large European study also demonstrated the rarity of
parathyroid carcinoma with an estimated incidence of 2
cases per 10,000,000 persons/year.
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Sign and Symptoms

Primary hyperparathyroidism is usually asymptomatic.
The clinical symptoms of the resulting hypercalcaemia
that it does cause can be remembered by the following
rhyme:
Bones: pain
Stones: renal stones
Abdominal groans: abdominal pain, constipation and
anorexia
Psychic moans: depression and anxiety
Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London.
Laycock, John. Integrated Endocrinology 1st Edition. 2014 Wiley-Blackwell. Oxford

Laboratory Examination
Serum calcium and phosphate
Serum alkaline phosphatase
PTH activity
Vitamin D acitivity
Urinary calcium and phosphate
Urinary hydroxyproline
Excretion of pyridinium compounds and telopeptides

Solomon Louis, Apley and Solomons Concise System of Orthopaedics and Trauma. 2014. Taylor and Francis Group

Radiological Examination
Ultrasound scan of the parathyroid glands to identify an
adenoma
Parathyroid scintigraphy, which shows increased tracer
uptake in an adenoma
DEXA scan, which shows osteoporosis secondary to
bone demineralisation
Renal tract ultrasound scan to show any asymptomatic
renal calculi

Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London. 2015

Treatment
Usually conservative and includes adequate hydration
and decreased calcium intake.
If an adenoma is present it should be removed.
Postoperatively Hungry Bone Syndrome. This must be
treated promptly, with one of the fast-acting vitamin D
metabolites.

Solomon Louis, Apley and Solomons Concise System of Orthopaedics and Trauma. 2014. Taylor and Francis Group

Indication of parathyroidectomy
The indications for parathyroidectomy are:
Symptomatic hypercalcaemia
Asymptomatic hypercalcaemia (calcium concentration
0.25 mmol/L above the upper limit of the normal range)
Osteoporosis
Chronic kidney disease
Renal stones

Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London. 2015

Prognosis
Removal of a single adenoma in primary hyperparathyroidism
is curative. With calcium and vitamin D replacement, bone
mineral density slowly improves.
In severe cases osteoclastic hyperactivity produces endosteal
cavitation and replacement of the marrow spaces by vascular
granulations and fibrous tissue (osteitis fibrosa cystica).
Haemorrhage and giant-cell reaction within the fibrous stroma
may give rise to brownish, tumor-like masses, whose
liquefaction leads to fluid-filled cysts (brown tumors).
Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London.
Solomon Louis, Apley and Solomons Concise System of Orthopaedics and Trauma. 2014. Taylor and Francis Group

Prognosis
Survival has varied widely in the literature, with 5-year
survival ranging from 20-85% and 10-year survival from
approximately 15-80%. Data from the US National
Cancer Data Base showed a 5-year survival of 88.5%
and a 10-year survival of 49.1%.

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Fox, Thomas. Eureka Endocrinology. 2015.

JP Medical London. 2015

Fox, Thomas. Eureka Endocrinology. 2015. JP Medical London. 2015

Take Home Message

If there is patient come to hospital with decrease of
bone mineral density but in young age, we have to
check/ think about metabolism bone disease.
Rare cases but does not mean never

Thank You