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 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  Acknowledgements
 ::  References
 ::  Article Figures

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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 4  |  Page : 197-200

Primary hyperparathyroidism due to (chief-cell hyperplasia- (a review with a case illustration)


Department of Thoracic Surgery, Rajendra Medical College, Ranchi., India

Correspondence Address:
H N Verma
Department of Surgery, Patna Medical College and Hospital, Patna-800 004
India
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Source of Support: None, Conflict of Interest: None


PMID: 615269

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 :: Abstract 

A 37 year old man presented with multiple pathological frac­tures, mental symptoms and features o f renal insufficiency without renal stones and nephrocalcinosis. This was found to be a case of primary hyperparathyroidism due to chief cell hyperplasia. Three parathyroids were removed leaving behind the right superior gland. The patient had temporary symptomatic improvement with the healing of the fractures of metacarpals. There was no union of fractures of necks of femora. The symptoms reappeared and the patient died of renal failure more than a year after operation.
Severe renal impairment is therefore the most important single complication in advanced osseous lesions. Even if parathyroidectomy is done in such advanced cases probably no permanent clinical improvement may be expected. Better results in these cases might be observed by early diagnosis of the disease and adequate surgery. It is hence suggested that in a case of parathyroid hyperplasia one should aim at excision o f 31- parathyroid glands, i.e., near total parathyroidectomy, to avoid recurrence of disease.



How to cite this article:
Verma H N. Primary hyperparathyroidism due to (chief-cell hyperplasia- (a review with a case illustration). J Postgrad Med 1977;23:197-200

How to cite this URL:
Verma H N. Primary hyperparathyroidism due to (chief-cell hyperplasia- (a review with a case illustration). J Postgrad Med [serial online] 1977 [cited 2020 Dec 3];23:197-200. Available from: https://www.jpgmonline.com/text.asp?1977/23/4/197/42755



 :: Introduction Top


Primary hyperparathyroidism is a rare and interesting condition. Below we describe a patient with primary hyperpara-thyroidism due to chief cell hyperplasia.


 :: Case report Top


G.L., a 37 year old Hindu male from West Bengal, was admitted into the Orthopaedic Ward of R.M.C. Hospital, Ranchi on 24-1-1970. He complained of backache, bone pains, diffi­culty in walking, anorexia and weight loss for 1 year. Initially, he was thought to have spinal tuberculosis and was treated accordingly. On 9-2-1970, he developed mental symptoms includ­ing confusion, hallucinations, nervousness, agi­tation and tremors of hands and feet. At this stage, a diagnosis of "Motor type of polyneuro­pathy" was made and he was treated with corticosteroids and with vitamin B 1 and B 12 . The patient did not respond to this treatment. On 21-4-1970, he was suspected to have primary hyperparathyroidism and was then transferred to the Surgical Ward of the hospital. On exami­nation at this stage, he was wasted, anemic, obviously ill-looking and was in agonising pain. His pulse. temperature and blood pressure were normal. There was limitation of move­ments of both hips. Systemic examination was negative. A skeletal survey showed (a) re­absorption of both femoral necks with patho­logical fractures and decalcification of pelvic bone see [Figure 1] on page 196B; (b) deminera­lization with fractures of the lower end of tibia and fibula; (c) loss of lamina dura of teeth see [Figure 2] on page 196B ; (d) multiple rib fractures and fluffy shadows in the chest see [Figure 3] on page 196B; (e) generalized demineralization with subperiosteal erosion of hands with frac­tures of the bases of 2nd metacarpals on both hands see [Figure 4] on page 198A ; (f) typical fuzzy appearance of both tables of the skull with ground glass appearance see [Figure 5] on page 198A ; (g) demineralization of the lateral end of the left clavicle and of the upper end of the left humerus with a fracture of the neck of the left scapula see [Figure 6] on page 198A ; similar decalcification was seen in other bones

There was no evidence of renal calculi. His serum calcium level varied between 10.8 mg% and 11.8 mg% and the serum phosphorus level between 3.22 mg and 4.3 mg%. Serum albumin was 3.64 gm% and serum globulin, 3.0 gm%. Blood urea was 34 mg%. Serum alkaline phos­phatase varied between 6.6 and 16.5 K.A. Units and the serum acid phosphatase was 7.0 K.A units. His hemoglobin was 9.0 gm%. Total and differential white cell count was normal, The urine showed a trace of protein, 2-4 pus cells per field and a lot of amorphous phosphate.

The patient was judged unfit for general anaesthesia and hence the neck was explored by a collar incision under local anaesthesia with careful dissection. The four parathyroid glands were individually isolated and found to be hyperplastic. They were removed leaving behind the right superior gland. The patient's condition was satisfactory at the end of the operation and his voice was intact. During the post-operative period, he was treated with Vitamin D 1 , cal­cium and a broad-spectrum antibiotic. Histo­pathological examination of the removed para­thyroid glands showed chief cell hyperplasia see [Figure 7] on page 198B.

In the early post-operative period, the general condition of the patient improved. He felt cheerful and the mental symptoms including confusion, hallucinations and nervousness dis­appeared. His serum calcium levels on 24-8-70,14-9-70, and 5-10-70 were 9.4 mg%, 9.7 mg% and 10.2 mg% respectively. Urine examination showed a trace of albumin and a few pus cells. The tremors of the hands and feet persisted with lesser severity. This was thought to be of functional in origin. X-ray of hands and pelvis on 17-9-70 showed some improvement in the rarefied areas and union of the fracture of the 2nd metacarpals see [Figure 8] on page 198B). There was no evidence of healing of fractures of both necks of femora. Further follow-up for six months showed a gradual improvement in the patient's general condition but later, it deteriorated. His previous mental symptoms re-appeared. His serum calcium rose gradually to 13.3 mg% by 24-9-1971. The pain in the bones and loss of appetite returned and frac­tures of both femoral necks failed to unite. At the end, he developed severe urinary infection with copious albuminuria and the passage of epithelial casts and pus cells. On 24-9-71 he became disoriented and stuporous and develop­ed uraemic features. He died on 27-9-71. An autopsy could not be done.


 :: Discussion Top


Primary hyperplasia is found in ap­proximately 5% in all cases of hyper­parathyroidism. Cope et a1 [4] reported only 8 cases of primary chief cell hyper­plasia out of 206 cases of primary hyper­parathyroidism. Pyrah et al [12] found only 2 cases of chief cell hyperplasia out of 68 cases of primary hyperparathyroidism. Straus et al [13] at the University of Chicago Hospital reported only 6 cases of primary hyperplasia of chief cell type out of 58 patients suffering from hyperpara­thyroidism. Primary hyperparathyroi­dism with advanced bony changes with­out apparent renal involvement was re­corded in 4 out of 53 cases of McGeown and Morrisson. [10] Seventeen such cases were found by Pyrah et al [12] out of sixty­-eight patients. Dent and Harper [5] regard­ed the osseous and renal lesions as two separate clinical entities, The present case had advanced bony lesions without renal stone or nephrocalcinosis. The case had bilateral fracture neck of femur simi­lar to one recorded by McGeown and Morrison. [11]

Although the patient had no obvious renal stone or nephrocalcinosis he show­ed features of renal damage. There was evidence of pyelonephritis with copious albuminuria and passage of epithelial casts. The severe impairement of renal function in worst type of osseous lesions, often in absence of any form of renal cal­cification, is believed to be due to micro­scopic damage to the renal tubules and their blockage by calcific debris (Pyrah et al [12] )

Edvall, [6] after reviewing 20 patients, found that the parathormone has two effects on the kidney: (a) a functional change which is reversible after surgery, and (b) on organic tubular lesion which is irreversible and persists after the ope­ration. He believed that the renal dis­turbances were mainly caused directly by the excessive amount of circulating parathormone in absence of renal calculi or nephrocalcinosis. Hellstorm and Ive­Mark [8] also showed that the incidence of such renal impairment was higher than that of renal calculi in patients with ad­vanced osseous lesions. Our patient also developed renal failure in the later stage and died of uraemia. The severe irrever­sible impairment of renal function in this patient could have been due to micro­scopic tubular damage. Karcher [9] review­ed 499 cases of hyperparathyroidism with 33 postoperative deaths, the most com­mon cause of which was renal failure.

This patient had severe mental symp­toms including confusion, hallucination, nervousness and tremors. They were relieved temporarily after the operation but reappeared later when serum cal­cium rose. Eitinger [7] reported a female patient with hyperparathyroidism in whom psychiatric and neurological chan­ges were the main presenting features. Bogdenoff and others [1] reported a female patient aged 58 years, with gross psychia­tric abnormalities and depression which improved temporarily following surgery but in whom the symptom's recurred after some months. These mental symptoms are possibly due to hypercalcemia and deposition of calcium phosphate salt in the brain.

In the present case, only three parathy­roids were removed and right superior parathyroid was left behind to avoid hypoparathyroidism. In the early post­operative period, the patient improved remarkably, but later on there was a gradual deterioration in his condition with a gradual rise in the serum calcium level. The mental symptoms recurred and the features of renal insufficiency ap­peared. This may be attributed to (i) in­adequate surgery or to (ii) advanced osseous lesions with irreversible renal damage. Churchill and Cope [3] advocated removal of 3 enlarged glands completely and a subtotal removal of 4th leaving be­hind amount of gland weighing 50 to 150 mg. Even after careful resection it is easy to leave too much of the parathyroid tissue. There is, therefore, less certainty of complete cure in a case of hyperplasia than in a case of an adenoma. Castleman and Cope [2] reported that none of their 11 cases of primary hyperplasia had been completely cured by subtotal resection.


 :: Acknowledgements Top


I wish to thank Dr. B. Singh, Superin­tendent, Rajendra Medical College Hos­pital, Ranchi for permission to report this case.

I am thankful to Prof. J. Sharan, Prof. of Pathology and Prof. N. D. Basu, Prof. of Radiology for their invaluable techni­cal assistance. I am grateful to Dr. Surendra Sinha, Physician-incharge for referring this case.

 
 :: References Top

1.Bogdonoff, M. D., Woods, A. H., White, J. E. and Engel, E. L.: Hyperparathyroi­dism, Amer. J. Med., 21: 583-591, 1956.  Back to cited text no. 1    
2.Castleman, B. and Cope, O.: Bull. Hosp. Jt. Diseases, 12: 368, 1951, as quoted by Pyrah et al. [12]   Back to cited text no. 2    
3.Churchill, E. D. and Cope, O.: Parathy­roid tumors associated with hyperpara­thyroidism. Surg. Gynec. Obst.. 58: 253­271, 1.934.  Back to cited text no. 3    
4.Cope, O., Keynes, W. M., Roth, S. I. and Castleman, B.: Primary Chief cell hyper­plasia of the parathyroid glands-a new entity in surgery of hyperparathyroidism. Ann. Surg., 148: 375-388, 1958.  Back to cited text no. 4    
5.Dent, C. E. and Harper, C. M.: Plasma alkaline phosphatase in normal adults and in patients with primary hyperparathy­thyroidism. Lancet, 1: 559-563, 1962.  Back to cited text no. 5    
6.Edvall, C. A.: Acta. Chir. Scandinav. Supplement No. 229, 1958, as quoted by Pyrah et al. [12]   Back to cited text no. 6    
7.Eitinger, L.: Nord. Med., 14: 1581. 1942, as quoted by Pyrah et al. [12]   Back to cited text no. 7    
8.Hellstrom, J. and Ivemark, B. I.: Acta. Chir. Scand. Supplement No. 294, I, 1962, as quoted by Pyrah et al. [12]   Back to cited text no. 8    
9.Karchar, H.: Ergebn. Chir. Orthop., 140: 92, 1958, as quoted by Pyrah et al. [12]  Back to cited text no. 9    
10. McGeown, M. G. and Morrison, E.: Hyperparathyroidism. Postgrad. Med. J., 35: 330-337, 1959.  Back to cited text no. 10    
11.McGeown, M. G. and Morrison, E.: "The Parathyroids" Recent Advances in Sur­gery. Editor: Taylor, S., 6th Edition, J. and Churchill Ltd., London, 1964, pp. 406-424.  Back to cited text no. 11    
12.Pyrah, L. N., Hodgkinson, A. and Ander­son, C. K.: Primary Hyperparathyroi­dism. Brit. J. Surg., 53: 245-316, 1966.  Back to cited text no. 12    
13.Strauss, F. H. and Paloyem, E.: The pathology of hyperparathyroidism. Surg. Clin. N. Amer., 49: 27-42, 1969.  Back to cited text no. 13    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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