title: Normocalcemic primary hyperparathyroidism: further characterization of a new clinical phenotype.
abstract: BACKGROUND
  Patients with elevated PTH and consistently normal serum calcium levels, in whom secondary causes of hyperparathyroidism have been excluded, may represent the earliest presentation of primary hyperparathyroidism (PHPT).
  
  
  OBJECTIVE
  The objective of the study was to characterize patients with normocalcemic PHPT referred to a bone disease unit.
  
  
  METHODS
  This was a longitudinal cohort study.
  
  
  METHODS
  Ambulatory patients were referred to the metabolic bone disease unit.
  
  
  METHODS
  The study population included 37 patients [aged 58 yr, range 32-78; 95% female; serum calcium, 9.4 +/- 0.1 (sem) mg/dl (2.3 +/- 0.02 mmol/liter), reference range, 8.5-10.4 (2.1-2.6 mmol/liter); PTH, 93 +/- 5 pg/ml].
  
  
  METHODS
  Interventions included yearly (median 3 yr; range 1-8 yr) physical examination, biochemical indices, and bone mineral density (BMD).
  
  
  METHODS
  We measured the development of features of PHPT.
  
  
  RESULTS
  Evaluation for classical features of PHPT revealed a history of kidney stones in five (14%), fragility fractures in four (11%), and osteoporosis in 57% [spine (34%), hip (38%), and/or distal one third radius (28%)]. BMD did not show preferential bone loss at the distal one third radius (T scores: spine, -2.00 +/- 0.25; hip, -1.84 +/- 0.18; one third radius, -1.74 +/- 0.22). Further signs of PHPT developed in 40% (seven hypercalcemia; one kidney stone; one fracture; two marked hypercalciuria; six had >10% BMD loss at one or more site(s) including four patients developing World Health Organization criteria for osteoporosis). Seven patients (three hypercalcemic, four persistently normocalcemic) underwent successful parathyroidectomy.
  
  
  CONCLUSIONS
  Patients seen in a referral center with normocalcemic hyperparathyroidism have more substantial skeletal involvement than is typical in PHPT and develop more features and complications over time. These patients may represent the earliest form of symptomatic, rather than asymptomatic, PHPT.
authors.affiliation: Department of Medicine, PH 8W-864, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, New York 10032, USA.
authors.forename: H
authors.initials: H
authors.lastname: Lowe
authors.forename: D J
authors.initials: DJ
authors.lastname: McMahon
authors.forename: M R
authors.initials: MR
authors.lastname: Rubin
authors.forename: J P
authors.initials: JP
authors.lastname: Bilezikian
authors.forename: S J
authors.initials: SJ
authors.lastname: Silverberg
mesh_terms: D000328:Adult; D000368:Aged; D015519:Bone Density; D002118:Calcium / Q000097:blood*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000097:blood* / Q000000981:diagnostic imaging / Q000601:surgery; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010024:Osteoporosis / Q000209:etiology; D016105:Parathyroidectomy; D010641:Phenotype; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D002118:Calcium