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Hypoparathyroidism

By

James L. Lewis III

, MD, Brookwood Baptist Health and Saint Vincent’s Ascension Health, Birmingham

Last full review/revision Mar 2021| Content last modified Mar 2021
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Hypoparathyroidism is a deficiency of parathyroid hormone often caused by an autoimmune disorder or by iatrogenic damage or removal of the glands during thyroidectomy or parathyroidectomy. Symptoms of hypoparathyroidism are due to hypocalcemia and include tingling in the hands or around the mouth and muscle cramps. In severe causes, tetany occurs. Symptoms and signs of the causative disorder may also be present. Measurement of levels of parathyroid hormone are needed for diagnosis. Treatment includes calcium and vitamin D supplementation.

Hypoparathyroidism is characterized by hypocalcemia and hyperphosphatemia and often causes chronic tetany.

Etiology

Hypoparathyroidism results from deficient parathyroid hormone (PTH), which can occur in

  • Removal of or damage to several parathyroid glands during thyroidectomy or parathyroidectomy

  • Inherited and autoimmune disorders

Postoperative hypoparathyroidism

Transient hypoparathyroidism is common after thyroidectomy, but permanent hypoparathyroidism occurs after < 3% of such thyroidectomies done by experienced surgeons. Manifestations of hypocalcemia usually begin about 24 to 48 hours postoperatively but may occur after months or years. PTH deficiency is more common after radical thyroidectomy for cancer or as the result of surgery on the parathyroid glands (subtotal or total parathyroidectomy). Risk factors for severe hypocalcemia after subtotal parathyroidectomy include

  • Severe preoperative hypercalcemia

  • Removal of a large adenoma

  • Elevated alkaline phosphatase

Idiopathic hypoparathyroidism

Idiopathic hypoparathyroidism is uncommon. It is a sporadic or inherited condition in which the parathyroid glands are absent or atrophied. It manifests in childhood. The parathyroid glands are occasionally absent and thymic aplasia and abnormalities of the tissue arising from the brachial arches (DiGeorge syndrome) are present.

Other inherited forms include polyglandular autoimmune failure syndrome, autoimmune hypoparathyroidism associated with mucocutaneous candidiasis, and X-linked recessive idiopathic hypoparathyroidism.

Pseudohypoparathyroidism

Pseudohypoparathyroidism is an uncommon group of disorders characterized not by hormone deficiency but by target organ resistance to PTH. Complex genetic transmission of these disorders occurs.

Type Ia pseudohypoparathyroidism (Albright hereditary osteodystrophy) is caused by a mutation in the stimulatory Gs-alpha1 protein of the adenylyl cyclase complex (GNAS1). The result is failure of normal renal phosphaturic response or increase in urinary cAMP (cyclic adenosine monophosphate) to PTH. Patients are usually hypocalcemic and hyperphosphatemic. Secondary hyperparathyroidism and hyperparathyroid bone disease can occur. Associated abnormalities include short stature, round facies, intellectual disability with calcification of the basal ganglia, shortened metacarpal and metatarsal bones, mild hypothyroidism, and other subtle endocrine abnormalities. Because only the maternal allele for GNAS1 is expressed in the kidneys, patients whose abnormal gene is paternal, although they have many of the somatic features of the disease, do not have hypocalcemia, hyperphosphatemia, or secondary hyperparathyroidism; this condition is sometimes described as pseudopseudohypoparathyroidism.

Type Ib pseudohypoparathyroidism is less well known. Affected patients have hypocalcemia, hyperphosphatemia, and secondary hyperparathyroidism but do not have the other associated abnormalities.

Type II pseudohypoparathyroidism is even less common than type I. In affected patients, exogenous PTH raises the urinary cAMP normally but does not raise serum calcium or urinary phosphate. An intracellular resistance to cAMP has been proposed.

Symptoms and Signs

The presence of hypoparathyroidism may be suggested by symptoms due to hypocalcemia, including tingling in the hands or around the mouth and muscle cramps. In severe cases, tetany occurs.

The clinical manifestations of any underlying disorder may be present. Patients with type Ia pseudohypoparathyroidism frequently have skeletal abnormalities, including short stature and shortened 1st, 4th, and 5th metacarpals, a round face, intellectual disability, basal ganglia calcification, and sometimes vitiligo. Patients with type Ib disease have renal manifestations of hypocalcemia and hyperphosphatemia without the skeletal abnormalities that occur in type Ia. Patients with type II pseudohypoparathyroidism also have the renal abnormalities. Patients with mutations involving the catalytic subunit of cAMP also have multiple hormonal resistance, intellectual disability, and short digits.

Diagnosis

  • PTH and calcium measurement

PTH concentration should be measured as an assay of the intact molecule. Because hypocalcemia is the major stimulus for PTH secretion, PTH normally should be elevated in response to hypocalcemia. Thus,

  • Low or even low-normal PTH concentration in patients with hypocalcemia is inappropriate and suggests hypoparathyroidism.

  • An undetectable PTH concentration suggests idiopathic hypoparathyroidism.

  • A high PTH concentration suggests pseudohypoparathyroidism or an abnormality of vitamin D metabolism

Hypoparathyroidism is further characterized by high serum phosphate and normal alkaline phosphatase.

In type I pseudohypoparathyroidism, despite the presence of a high concentration of circulating PTH, urinary cAMP and urinary phosphate are absent. Provocative testing by injection of parathyroid extract or recombinant human PTH fails to raise serum or urinary cAMP.

Treatment

  • Calcium and vitamin D

In transient hypoparathyroidism after thyroidectomy or partial parathyroidectomy, supplemental oral calcium may be sufficient: 1 to 2 g of elemental calcium/day may be given as calcium gluconate (90 mg elemental calcium/1 g) or calcium carbonate (400 mg elemental calcium/1 g).

Subtotal parathyroidectomy may cause hypocalcemia that is particularly severe and prolonged, particularly in patients with chronic kidney disease or in patients from whom a large tumor was removed. Prolonged parenteral administration of calcium may be necessary postoperatively; intravenous supplementation with as much as 1 g/day of elemental calcium (eg, 111 mL/day of calcium gluconate, which contains 90 mg elemental calcium/10 mL) may be required for 5 to 10 days before oral calcium and vitamin D are sufficient. Elevated serum alkaline phosphatase in such patients may be a sign of rapid uptake of calcium into bone. The need for large amounts of parenteral calcium usually does not fall until the alkaline phosphatase concentration begins to decrease.

Hypoparathyroidism that does not respond adequately to calcium and vitamin D supplementation may require treatment with recombinant parathyroid hormone (rhPTH), which also may decrease the risk of long-term hypoparathyroidism complications (eg, hypercalciuria, decreased bone mineral density) and lower the doses of calcium and vitamin D needed. Dosing of rhPTH begins with 50 mcg subcutaneously once a day along with a decrease in vitamin D dosing by 50%. Serum calcium and phosphate are monitored closely and the dose of rhPTH is increased or decreased at intervals of several weeks as needed up to a maximum of 100 mcg once a day or down to 25 mcg once a day.

Key Points

  • Hypoparathyroidism is a deficiency of parathyroid hormone often caused by an autoimmune disorder or removal of the glands during thyroidectomy.

  • Hypoparathyroidism causes hypocalcemia and related symptoms of tingling in the hands or around the mouth and muscle cramps. In severe causes, tetany occurs.

  • Diagnosis is made by finding low or even low-normal PTH concentrations in a patient with hypocalcemia.

  • Treatment is with calcium and vitamin D. Some patients require recombinant parathyroid hormone (rhPTH).

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