Parathyroid storm: immediate recognition and pathophysiological considerations.
A 56-year-old white man was referred for evaluation of severe hypercalcemia following a three-week history of progressive weakness, nausea, and depression. Initial laboratory results showed serum total and ionized calcium (Ca++) values of 5.3 and 2.6 mmol/l, respectively. A short intact PTH assay was immediately performed and an extremely high value was obtained in just 30 min (1315 ng/l, normal values 6.4-70.4). The patient was therefore treated with saline solution and with salmon calcitonin (1200 IU/day, half by continuous i.v. infusion and half by i.m. route) for 10 days. There was a sudden decrease of both Ca++ and intact PTH during the first six days; then there was a trend to reach a steady-state until parathyroidectomy was performed. After withdrawal of calcitonin therapy it was possible to observe a positive uncoupling between bone formation (serum alkaline phosphatase and osteocalcin) and resorption (serum tartrate-resistant acid phosphatase) markers. On day 35 the patient underwent neck exploration, and an enlarged lower left parathyroid gland was removed that on macroscopic examination revealed the presence of a haemorrhagic cyst; microscopic appearance was suggestive of a previous glandular infarction. This is the first time the daily clinical course of a parathyroid crisis has been documented. Furthermore, changes of biomarkers of bone turnover following calcitonin therapy show that high doses of the hormone may cause a prolonged positive uncoupling of the two processes of bone remodeling.
Minisola
S
S
Istituto di II Clinica Medica, Università degli Studi di Roma La Sapienza, Italy.
Romagnoli
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E
Scarnecchia
L
L
Pacitti
M T
MT
Rosso
R
R
Carnevale
V
V
Minisola
G
G
Mazzuoli
G
G
D000135:Acid Phosphatase / Q000097:blood; D000469:Alkaline Phosphatase / Q000097:blood; D015415:Biomarkers / Q000097:blood; D016723:Bone Remodeling; D002116:Calcitonin / Q000008:administration & dosage / Q000627:therapeutic use*; D002118:Calcium / Q000097:blood*; D006801:Humans; D006934:Hypercalcemia / Q000175:diagnosis; D006961:Hyperparathyroidism / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy / Q000503:physiopathology*; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D015675:Osteocalcin / Q000097:blood; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage / Q000627:therapeutic use
D015415:Biomarkers; D010281:Parathyroid Hormone; D012462:Saline Solution, Hypertonic; D015675:Osteocalcin; C028815:salmon calcitonin; D002116:Calcitonin; D000469:Alkaline Phosphatase; D000135:Acid Phosphatase; D002118:Calcium