Hiperparatiroidismo primario por carcinoma paratiroideo: caso problema y revisión / Primary hyperparathyroidism by parathyroid cancer: case report and review

El carcinoma paratiroideo (CP) es una neoplasia maligna con una incidencia de 0,015 cada 100.000 habitantes por año. Representa el 1% de los diagnósticos de hiperparatiroidismo primario y se manifiesta entre la 4.a y 5.a década de la vida, con una incidencia similar entre hombres y mujeres. La etiología del CP es incierta, ha sido asociada a formas esporádicas o familiares. Está caracterizado por altos niveles séricos de calcio y PTH y el desafío clínico-quirúrgico es el diagnóstico diferencial con otras entidades benignas como el adenoma o la hiperplasia de paratiroides. Aunque el diagnóstico de certeza es anatomopatológico, la sospecha clínica y el uso de métodos de baja complejidad (ecografía) con operadores avezados permite una correcta localización y abordaje pertinente del paciente para dirigir el tratamiento quirúrgico adecuado (resección en bloque) evitando persistencias y recurrencias de enfermedad. Se presenta el caso clínico de un paciente masculino que ingresa por síndrome de impregnación asociado a hipercalcemia, su abordaje diagnóstico, tratamiento y manejo interdisciplinario con discusión y revisión bibliográfica. (AU)

Parathyroid carcinoma (CP) is a malignant disease with an incidence of 0.015 per 100,000 inhabitants per year. It accounts for 1% of primary hyperparathyroidism diagnoses and occurs between the 4th and 5th decade of life, with a similar incidence between men and women. The etiology of CP is uncertain and has been associated with sporadic or family forms. CP is characterized by high serum calcium and PTH levels and the clinical-surgical challenge is the differential diagnosis with other benign entities such as parathyroid adenoma or hyperplasia. Although the diagnosis of certainty is achieved by pathological anatomy examination, the clinical suspicion and the use of low complexity methods (ultrasound) by experienced operators allows a correct localization and a patient-specific approach to direct the appropriate surgical treatment (block resection), avoiding persistence and recurrences of disease. The clinical case of a male patient admitted for severe hypercalcemia with multiple organ disfunction, the diagnostic approaches, treatment, and interdisciplinary management, together with review and discussion of the current literature are presented. (AU)

Hipoparatiroidismo y calcificaciones cerebrales: reporte de caso / Hypoparathyroidism and brain calcifications: a case report

Introducción. El hipoparatiroidismo es una enfermedad caracterizada por la ausencia o concentraciones inadecuadamente bajas de hormona paratiroidea (PTH), que conduce a hipocalcemia, hiperfosfatemia y excreción fraccional elevada de calcio en la orina. Las calcificaciones del sistema nervioso central son un hallazgo frecuente en estos pacientes. Caso clínico. Mujer de 56 años con antecedente de hipotiroidismo, que ingresó por un cuadro de 6 días de evolución caracterizado por astenia, parestesias periorales y movimientos anormales de manos y pies. Las pruebas de laboratorio demostraron hipocalcemia, hiperfosfatemia y niveles bajos de hormona paratiroidea. Se realizó una tomografía computarizada de cráneo que mostró áreas bilaterales y simétricas de calcificaciones en hemisferios cerebelosos, ganglios basales y corona radiata. No se evidenciaron trastornos en el metabolismo del cobre y hierro. Se estableció el diagnóstico del síndrome de Fahr secundario a hipoparatiroidismo y se inició tratamiento con suplementos de calcio y vitamina D con evolución satisfactoria. Discusión. El síndrome de Fahr es un trastorno neurológico caracterizado por el depósito anormal de calcio en áreas del cerebro que controlan la actividad motora. Se asocia a varias enfermedades, especialmente, hipoparatiroidismo. La suplementación con calcio y vitamina D con el objetivo de normalizar los niveles plasmáticos de estos cationes es el tratamiento convencional. (AU)

Introduction. Hypoparathyroidism is a disease characterized by absence or inappropriately low concentrations of circulating parathyroid hormone, leading to hypocalcaemia, hyperphosphataemia and elevated fractional excretion of calcium in the urine. Central nervous system calcifications are a common finding in these patients. Case report. 56-year-old woman with a history of hypothyroidism who was admitted for a 6-day course of illness characterized by asthenia, perioral paresthesias, and abnormal movements of the hands and feet. Laboratory tests showed hypocalcemia, hyperphosphatemia, and low parathyroid hormone levels. A cranial computed tomography was performed. It showed bilateral and symmetrical areas of calcifications in the cerebellar hemispheres, basal ganglia, and radiata crown. No disorders of copper or iron metabolism were evident. The diagnosis of Fahr syndrome secondary to hypoparathyroidism was established and treatment with calcium and vitamin D supplements was started with satisfactory evolution. Discussion. Fahr's syndrome is a neurological disorder associated with abnormal calcium deposition in areas of the brain that control motor activity. It is associated with various diseases, especially hypoparathyroidism. The conventional treatment is supplementation with calcium and vitamin D, with the aim of normalizing their plasma levels. (AU)

Toxicidad por ácido fluorhídrico: reporte de casos / HYdrofluoric acid toxicity

Los accidentes con ácido fluorhídrico en Argentina son un motivo de consulta infrecuente, a pesar de ser utilizado en varias actividades laborales. Es uno de los pocos cáusticos con tratamiento específico que se debe tener en cuenta. Reportamos el caso de un paciente de 35 años que estuvo en contacto con esta sustancia con posterior compromiso de miembro superior, presentando placa eritematosa en región palmar derecha y lesión ampollar con descamación posterior y sangrado en lecho ungueal. Recibió tratamiento local con gluconato de calcio al 20% en toda la extensión de la zona afectada durante 48 hs con recuperación completa a los quince días. La sospecha clínica temprana y la administración adecuada de gluconato de calcio evitan lesiones de mayor grado y extensión

In Argentina, hydrofluoric acid accidents are a rare reason for consultation, despite being a commonly used substance in laboral activities. It is one of the few caustics with a specific treatment that must be taken into account. We report the case of a 35 year old patient affected by said substance, in which we observe an impairment of the upper limb, presenting on the right palmar region, an erythematous plaque with a blister lesion with posterior scaling and bleeding of the nail bed. The importance of the early clinical suspicion and the proper administration of calcium gluconate would avoid bigger and more extensive lesions

Crisis hipercalcémica causada por adenoma paratiroideo: reporte de un caso clínico / Hypercalcemic crisis due to parathyroid adenoma: report of a clinical case

La hipercalcemia es un trastorno común que representa aproximadamente el 0,6% de todas las admisiones médicas agudas. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las dos causas más comunes de elevación de los niveles séricos de calcio; constituyen, en conjunto, alrededor del 90% de todos los casos. La presentación sintomática clásica de la hipercalcemia se observa con relativa poca frecuencia en el mundo desarrollado; la presentación más común es la detección asintomática en las pruebas bioquímicas. Sin embargo, en casos raros, el HPTP puede desarrollar hipercalcemia aguda, grave y sintomática, llamada crisis hipercalcémica (CH). Esta condición se asocia a alteraciones profundas en el estado mental y las funciones cardíaca, renal y gastrointestinal en presencia de concentraciones marcadamente elevadas de calcio sérico y paratohormona (PTH). Mientras que algunas elevaciones en el calcio sérico pueden ser bien toleradas, los síntomas de la CH son severos. Si el tratamiento se retrasa, la CH puede provocar la muerte. Describimos el caso de un paciente masculino que ingresa en la unidad de cuidados críticos por una CH secundaria a un HPTP por adenoma paratiroideo. (AU)

Hypercalcaemia is a most common disorder, accounting for approximately 0,6% of all acute medical admissions. Primary hyperparathyroidism (PHPT) and malignancy are the two most common causes of increased serum calcium levels, together accounting for about 90% of all cases. The classical symptomatic presentation of hypercalcaemia is seen relatively rarely in the developed world, the most common presentation being asymptomatic and detected following on biochemical testing. However, in rare cases HPTP can result in acute, severe and symptomatic hypercalcemia, called hypercalcemic crisis (HC). This condition is associated with profound disturbances in mental status, and cardiac, renal, and gastrointestinal function in the presence of markedly increased serum calcium and parathyroid hormone (PTH) concentrations. While some elevations in serum calcium can be well tolerated, symptoms of HC are severe. If treatment is delayed, HC can result in death. We describe herein a case of a male patient who was admitted to the intensive care unit as a consequence of HC resulting from elevated PTH, secondary to a parathyroid adenoma. We describe the case of a male patient who was admitted to the critical care unit for a HC mediated by PTH secondary to a parathyroid adenoma. (AU)

An insulinoma with an aberrant feeder from the splenic artery detected by super-selective arterial calcium stimulation with venous sampling

No abstract available.

Predicting postoperative total calcium requirements after parathyroidectomy in secondary hyperparathyroidism

BACKGROUND/AIMS: To prevent hypocalcemia after parathyroidectomy (PTX), parenteral calcium is required in addition to oral calcitriol and calcium. After switching to oral calcium, patients can be discharged from the hospital. The aim of this study was to analyze the clinical characteristics and outcomes of PTX performed at a single Korean center and to investigate the associated laboratory factors used to analyze the total amount of postoperative calcium required. METHODS: We enrolled 91 hemodialysis patients undergoing PTX from November 2003 to December 2011. We collected clinical and laboratory data preoperatively, 12 and 48 hours postoperatively, at discharge, and 3 and 6 months postoperatively. RESULTS: In total, 59 patients underwent PTX with autotransplantation (AT), 6 underwent total PTX without AT, 11 underwent subtotal PTX, and 15 underwent limited PTX. Total PTX without AT showed the lowest recurrence rate. At all postoperative time points, the mean levels of serum calcium, phosphorus, and intact parathyroid hormone (iPTH) decreased significantly, compared with preoperative levels; however, alkaline phosphatase (ALP) increased significantly from 48 hours postoperatively to discharge (p < 0.001). On multiple linear regression analysis, the total amount of injected calcium during hospitalization showed a significant correlation with preoperative ALP (p < 0.001), preoperative iPTH (p = 0.037), and Deltaphosphorus at 48 hours (p < 0.001). We developed an equation for estimating the total calcium requirement after PTX. CONCLUSIONS: Preoperative ALP, preoperative iPTH, and Deltaphosphorus at 48 hours may be significant factors in estimating the postoperative calcium requirement. The formula for postoperative calcium requirement after PTX may help to predict the duration of postoperative hospitalization.

Cost-effectiveness analysis regarding postoperative administration of vitamin-D and calcium after thyroidectomy to prevent hypocalcaemia / Análisis de costo-efectividad de la administración postoperatoria de Vitamina D y calcio después de tiroidectomía para la prevención de la hipo calcemia

Objective Hypocalcaemia is a frequently arising complication following total thyroidectomy. Routine postoperative prophylactic administration of vitamin D or metabolites and calcium reduce the incidence of symptomatic hypocalcaemia; this article reports evaluating its cost-effectiveness in Colombia. Methods Meta-analysis was used for comparing the administration of vitamin D or metabolites to oral calcium or no treatment at all in patients following total thyroidectomy and a cost-effectiveness analysis was designed based on a decision-tree model with local costs. Results The OR value for the comparison between calcitriol and calcium compared to no treatment and to exclusive calcium treatment groups was 0.32 (0.13-0.79 95 %CI) and 0.31 (0.14-0.70 95 %CI), respectively. The most cost-effective strategy was vitamin D or metabolites and calcium administration, having a US $0.05 incremental cost-effectiveness ratio. Conclusion Prophylactic treatment of hypocalcaemia with vitamin D or metabolites + calcium or calcium alone is a cost-effective strategy.

Objetivos La hipo calcemia es la complicación más frecuente después de tiroidectomía. La administración profiláctica de vitamina D o metabolitos y calcio reduce la incidencia de hipocalcémia sintomática. Se evalúa su costo-efectividad en Colombia. Materiales y métodos Utilizamos la información de un meta-análisis que comparó la administración de vitamina D o metabolitos contra calcio no tratamiento en pacientes llevados a tiroidectomía total y diseñamos un análisis de costo-efectividad basados en un modelos de decisiones con costos locales. Resultados El valor del OR para la comparación entre calcitriol y calcio comparado con no tratamiento o calcio exclusivo fue de 0.32 (95 % IC, 0.13- 0.79) y 0.31 (95 % IC, 0.14-0.70), respectivamente. La estrategia más costo-efectiva fue la administración de vitamina D o metabolitos y calcio, con una relación de costo-efectividad incremental de US $0.05. Conclusiones El tratamiento profiláctico de la hipo calcemia con vitamina D o metabolitos y calcio o calcio exclusivo después de tiroidectomía total es una estrategia costo-efectiva.

Queimadura por ácido hidrofluorídrico e descontaminação com quelante anfótero e gluconato de cálcio: relato de caso / Hydrofluoric acid burn and decontamination with amphoteric chelator and calcium gluconate: case report

Um trabalhador sofreu projeção de ácido hidrofluorídrico a 70% de concentração em aproximadamente 10% de superfície corpórea (SC), causando queimaduras químicas de 1º, 2º e 3º graus em face, tronco e membro inferior esquerdo. A descontaminação inicial envolveu enxágue com água, remoção da vestimenta, e enxágue adicional com mais água, bem como aplicação tópica de solução de óxido de magnésio e analgésico intravenoso para controle da dor. Após retardo de aproximadamente 3 horas, realizou-se descontaminação ativa com 5 litros de solução ativa de um quelante anfótero, Hexafluoriner, seguida de aplicação intravenosa, intradérmica perilesional e tópica de gluconato de cálcio. Alívio da dor e sensação refrescante foram relatados após aplicação do quelante. Não ocorreu intoxicação sistêmica significante, embora isto tenha ocorrido em casos previamente relatados de exposição ao ácido hidrofluorídrico concentrado. Apesar das queimaduras, o paciente foi liberado da Unidade de Terapia Intensiva após 2 dias, e os tratamentos cirúrgicos posteriores, enxertia, tiveram bons resultados.

A worker was splashed with 70% hydrofluoric acid (HF), sustaining approximately 10% total body surface area (TBSA) 1st-3rd degree chemical skin burns on the face, trunk and left leg. Initial decontamination involved water rinsing, removal of clothing, and more water rinsing, as well as topical application of a magnesium oxide solution and administration of intravenous narcotics for management of severe pain. After a delay of approximately 3 hours, the active skin decontamination solution Hexafluoriner, 5 liters, was used followed by intravenous, intradermal perilesional and topical application of calcium gluconate. Pain relief and a cooling sensation were quite prompt. No significant systemic toxicity occurred, although this has occurred in previously reported concentrated HF exposure cases. While burns did develop, the patient was released from the intensive care service after 2 days and after skin grafting had a good outcome.

Hyperinsulinemic-euglycemic therapy for intoxication with calcium channel blockers

Conventional therapy for intoxication with calcium channel blockers consists of crystalloid solutions, calcium gluconate, glucagon and vasopressor agents. These therapies often fail to improve hemodynamic function in intoxicated patients. The pathophysologic mechanism proposed for intoxication with these agents, suggest hypoinsulinemia as the determinant factor. We will describe the case of a 77 years old man treated for an overdose of nifedipine and atenolol who arrived at our institution with hypotension and bradycardia. After conventional therapy failed to improve the patient's hemodynamic status, hyperinsulinemia and euglycemia contributed to the improvement of the patient's neurologic and hemodynamic condition. Thus, hyperinsulinemic-euglycemic therapy was of benefit in this patient with hemodynamic compromise secondary to intoxication with calcium channel blocker not responding to conventional therapy. We will review the mechanism of action of calcium channel blocker drugs as well as the clinical presentation and treatment options for calcium channel blocker intoxication.

Pharmacokinetics of oxytetracycline in presence of calcium gluconate in goats.

The concentration of oxytetracycline (OTC) in plasma, after single dose i.v. administration at 10 mg kg-1, was determined during pre and post induced-hypercalcemia in goats. The pharmacokinetic variables were then calculated. Hypercalcemia caused several changes in the determined variables. The CPmax and CPmin of OTC observed at 0.08 and 4 hr in normal goats were respectively 34.50 +/- 1.65 and 1.19 +/- 0.14 micrograms ml-1, while the CPmax and CPmin of OTC in presence of calcium at 0.08 and 8 hr were 20.81 +/- 2.18 and 1.04 +/- 0.05 micrograms ml-1 respectively. Hypercalcemic state in goats increased t1/2 (alpha) (0.19 +/- 0.02 hr), t1/2 (beta) (2.77 +/- 0.03 hr), AUC (37.67 +/- 0.83 micrograms x hr x ml vd (area) (1.07 +/- 0.03 L kg-1) and vd (ss) (0.95 +/- 0.04 L kg-1) values of OTC compared to normal goats. The semilogarithmic plot of plasma level-time profile of OTC administered i.v. showed biphasic decline suggestive of two compartment open model 'kinetics' in both normal and hypercalcemic animals.

Hipercalciuria idiopática: diagnóstico diferencial / Idiopathic hypercalciuria. Differential diagnosis

Se evaluaron 50 pacientes portadores de hipercalciuria idiopática pesquisados a través de hematuria o litiasis y a 15 niños sanos controles. Todos ellos fueron sometidos a una prueba de restricción y sobrecarga de calcio, observándose tres distintos tipos de respuesta. El primer grupo (n = 21; 42%) presentó índices de calciuria/creatininuria postrestricción de calcio inferiores a 0,21 y mayores de 0,28 después de la sobrecarga, lo que permitió catalogarlos de hipercalciuria absortiva. El segundo grupo (n = 16; 32%) presentó ambos índices sobre 0,21, por lo que se catalogaron como subtipo renal, y en el tercero (n = 16; 26%) las cifras obtenidas no permitieron su inclusión dentro de alguno de los dos subtipos precedentes. Nuestros resultados permiten concluir que mediante la aplicación ambulatoria de una prueba de restricción y sobrecarga de calcio es posible separar a los pacientes portadores de hipercalciuria idiopática en los subgrupos absortivo y renal, lo que resulta una valiosa ayuda desde el punto de vista terapéutico. Es necesario realizar estudios más completos para explicar la existencia de un subgrupo de errático comportamiento frente al ensayo, que probablemente representa formas intermedias entre los subtipos descritos