Case: PARATHYROID ADENOMA WITH RENAL STONES A 50-year old male entered the emergency room with right

flank pain. The stone was subsequently passed spontaneously and analysis revealed it to be calcium oxalate. He had noted lethargy, polyuria, polydipsia, muscle weakness and diffuse bone pain. Laboratory results showed plasma calcium of 12.3 mg/dl, phosphate of 1.9 mg/dl, creatinine of 1.5 mg/dl, and albumin of 5.9 g/dl. His plasma alkaline phosphatase and urinary hydroxyproline were elevated. Urinary calcium excretion was 380 mg/24 hours. After water deprivation, urine osmolality did not exceed 290 mOsm/kg. A single, very large parathyroid gland was surgically removed from the patients neck. His serum calcium level decreased to 6 mg/dl. Notes: Parathyroid Gland, located at the neck, is responsible for the production of Parathyroid Hormone (PTH) which regulates the level of calcium and phosphate in the blood and bone. Parathyroid Hormone is produced by the chief cell. Parathyroid Adenoma is a noncancerous (benign) tumor of the parathyroid glands. LEARNING OBJECTIVES: 1. Identify the most likely hormonal causes of hypercalcemia in this case. Increased production of Parathyroid Hormone (PTH) or Hyperparathyroidism due to parathyroid adenoma causes the increase amount of Calcium in the body.

4. Explain the mechanism for the following a. Renal stones In the kidneys Ca is reabsorbed in the Distal Tubule. Hyperparathyroidism increases the amount of Ca, thus the increase in the amount of Ca will exceed the renal threshold for reabsorption of Calcium and it will precipitate causing renal stones. Bone pain

Because of the hypersecretion of PTH, it will activate osteoclast and increase bone resorption, this increase of PTH creates microfissures in bones where blood and other impurities tend to collate. This stimulates the nociceptors in the bones which signals pain.
c. Polyuria Hypercalcemia inhibits ADH thus causing polyuria. It disrupts the osmotic gradient in the tubules and also the receptor sites of ADH. d. Elevated alkaline phosphate

Alkaline phosphatase is an enzyme that liberates phosphate from bones or the liver. The increase in Alkaline Phosphate is due to increased bone resorption due to high levels of PTH.
e. Elevated urinary hydroxyproline One of the main components of bone is collagen and it containes appreciable quantities of hydroxyprolone. And due to bone resorption, there is a destruction of the organic matrix of the bone (collagen), which will be excreted in the urine. 5. Discuss the two mechanisms for the reduction of serum calcium after surgery 1. In the bone, removal of the adenoma will cause bone resorption to stop. Calcium will be reabsorbed back into the bone thus decreasing the amount of the serum calcium. 2. In the kidneys, removal of the adenoma will cause a decrease in Ca excretion thus lowering the amount of serum calcium

2. Discuss the mechanism for hypercalcemia

induced by the different hormonal causes Parathyroid Hormone(PTH) controls the level of calcium in the blood and bone. Hyperparathyroidism or increased production of Parathyroid Hormone will cause an increase in plasma Ca+ by - stimulating bone resorption - increasing Ca+ reabsorption of the kidneys - stimulating the production of calcitriol 3. Compare the effect of parathyroid hormone and vitamin D on plasma phosphate level -PTH increases amount of Calcium but decreases the amount of Phosphate. -Vitamin D or Calcitriol increases the amount of Calcium as well as the amount of Phosphate