hydration and gentle diuresis with furosemide, the most likely therapeutic
approach would be
a. Administration of maintenance doses of steroids
b. Radiation treatment for bony metastases
c. Neck exploration and resection of three out of four parathyroid glands
d. Neck exploration and resection of a parathyroid adenoma
e. Avoidance of sunlight, vitamin D, and calcium-containing dairy products
Q2. This 30-year-old woman presented with weakness, bone pain, an elevated parathormone level,
and a serum calcium level of 15.2 mg/dL. Skeletal survey films were taken, including the hand films and
chest x-ray shown.
a. Sarcoidosis
b. Vitamin D intoxication
c. Paget’s disease
d. Metastatic carcinoma
e. Primary hyperparathyroidism
The Answers are Neck exploration and resection of a parathyroid adenoma and Primary Hyperparathyroidism. This patient’s presentation and films are consistent with primary hyperparathyroidism. The elevated parathormone level (PTH) confirms
ReplyDeletethe diagnosis. Her chest film demonstrates marked osteopenia and the hand films are classic for this disease with severe demineralization and periosteal bone resorption most prominent in the middle phalanges. The
films show no evidence of malignant lesions or mediastinal adenopathy consistent with sarcoidosis, and an elevated PTH level is not found in Paget’s disease or vitamin D intoxication.
Treatment for primary hyperparathyroidism in this setting is resection of the diseased parathyroid glands after initial correction of the severe hypercalcemia. A neck exploration would yield a single parathyroid adenoma
in about 85% of cases. Two adenomata are found less often (approximately 5%) and hyperplasia of all four glands occurs in about 10–15% of
patients. If hyperplasia is found, treatment includes resection of three and one-half glands. The remnant of the fourth gland can be identified with a metal clip in case reexploration becomes necessary. Alternatively, all four glands can be removed with autotransplantation of a small piece of parathyroid tissue into the forearm or sternocleidomastoid muscle. Subsequent
hyperfunction, should it develop, can then be treated by removal of this tissue.
A patient with osteopenia this severe will need calcium supplementation postoperatively. Vitamin D supplementation may also be necessary if hypocalcemia develops and persists despite treatment with oral calcium.