Primary hyperparathyroidism

Last reviewed: 3 Sep 2022
Last updated: 21 Sep 2021

Summary

Definition

History and exam

Key diagnostic factors

  • incidental finding on biochemical testing
  • history of osteoporosis or osteopenia
  • family history of hyperparathyroidism or features suggestive of hypercalcaemia
  • nephrolithiasis
More key diagnostic factors

Other diagnostic factors

  • poor sleep
  • fatigue
  • myalgia
  • anxiety
  • depression
  • memory loss
  • overt neuromuscular dysfunction
  • cardiovascular and metabolic dysfunction
  • features suggestive of hypercalcaemia
  • hard and dense neck mass
Other diagnostic factors

Risk factors

  • female sex
  • age ≥50-60 years
  • family history of PHPT
  • multiple endocrine neoplasia (MEN) 1, 2A, or 4
  • current or historical lithium treatment
  • hyperparathyroidism-jaw tumour syndrome
  • history of head and neck irradiation
More risk factors

Diagnostic investigations

1st investigations to order

  • serum calcium
  • serum intact PTH with immunoradiometric or immunochemical assay
More 1st investigations to order

Investigations to consider

  • 25-hydroxyvitamin D level
  • serum alkaline phosphatase
  • serum phosphorus
  • 24-hour urinary calcium
  • dual-energy x-ray absorptiometry (DXA) scan
  • trabecular bone score
  • Tc-99m sestamibi scanning and ultrasonography
  • single photon emission CT + sestamibi scanning
  • CT neck
  • 4-Dimensional (4D) CT neck
  • MRI neck
More investigations to consider

Emerging tests

  • radiolabelled choline PET

Treatment algorithm

ONGOING

asymptomatic with surgical indications or symptomatic

asymptomatic with no surgical indications

Contributors

Authors

John Ayuk, MD

Consultant Endocrinologist

University Hospitals Birmingham

Birmingham

UK

Disclosures

JA declares that he has no competing interests.

Neil Gittoes, MD, PhD

Consultant Endocrinologist and Honorary Professor of Endocrinology

Associate Medical Director

University Hospitals Birmingham

Birmingham

UK

Disclosures

NG has contributed to advisory boards for Takedo and Shire pharmaceuticals.

Acknowledgements

Dr John Ayuk and Professor Neil Gittoes would like to gratefully acknowledge Dr Fausto Palazzo, Dr Swaroop Gantela, and Dr Nancy D. Perrier, the previous contributors to this topic. FP, SG, and NDP declare that they have no competing interests.

Peer reviewers

Bridget Sinnott, MD

Clinical Assistant

Professor of Medicine

University of Illinois at Chicago

Chicago

IL

Disclosures

BS declares that she has no competing interests.

Udaya Kabadi, MD

Professor of Medicine

Department of Internal Medicine

University of Iowa

Iowa City

IA

Disclosures

UK declares that she has no competing interests.

Leonard Egede, MD

Professor of Medicine

Medical University of South Carolina

Charleston

SC

Disclosures

LE declares that he has no competing interests.

Petros Perros, BSc, MBBS, MD, FRCP

Department of Endocrinology

Elliott Building

Royal Victoria Infirmary

Newcastle-upon-Tyne

UK

Disclosures

PP declares that he has no competing interests.

  • Differentials

    • Familial hypocalciuric hypercalaemia (FHH)
    • Humoral hypercalcaemia of malignancy
    • Multiple myeloma
    More Differentials
  • Guidelines

    • The EANM practice guidelines for parathyroid imaging
    • ACR–SPR Practice Parameter for the Performance of Parathyroid Scintigraphy
    More Guidelines
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