Primary hyperparathyroidism

Elevated parathyroid hormone leading to increased turnover of bone

Solitary adenoma or part of multiple endocrine neoplasia (MEN); nephrolithiasis. peptic ulcers and mental changes (bones, groans, etc.)

Hypercalcemia, hypophosphatemia, elevated PTH

Medical therapy for mild symptoms; surgery for symptoms or hypercalciuria, renal insufficiency, or osteoporosis

Lithium therapy

Stimulation of PTH

Same as with primary hyperparathyroidism

Same as with primary hyperparathyroidism

Discontinue lithium if symptoms

Malignancy-related hypercalcemia

Local destruction of bone (multiple myeloma or leukemia or lymphoma) or humoral release of PTHrH (solid tumors such as breast, renal, or lung cancer)

Symptoms of hypercalcemia and of the particular cancer

Imaging of bones (either plain film or CT). PTHrP levels, bone marrow biopsy

Treatment of the tumor and control of cancer, biphosphonates

Sarcoidosis (and other granulomatous disorders)

Excess 1.25(OH),D synthesized in macrophages and lymphocytes

Usually few symptoms

Low PTH levels and elevated l,25(OH),D levels

Avoidance of sunlight, decrease vitamin D and calcium intake: glucocorticoids if needed

Excessive vitamin D intake

Increased calcium intestinal absorption and, if severe, bone resorption

Symptoms of hypercalcemia

Low PTH levels, markedly elevated levels of 25(OH)D. and normal 1.25(OH),D levels

Glucocorticoids and. if needed, intensive hypercalcemia management

Renal insufficiency

Secondary hyperparathyroidism as a result of partial resistance to PTH effects

Bone pain, pruritus, ectopic calcification, osteomalacia

Elevated renal function tests

Limit dietary phosphate intravenous calcitriol

PTHrP = Parathyroid hormone-related protein: PTH = Parathroid hormone

Table 36-2

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