Thyroid and Parathyroid

stones (64 percent), bone disease (20 percent), peptic ulcer disease (12 percent), and
hypertension (4 percent). Walter St. Goar, in 1957, first used the mnemonic
“Hyperparathyroidism is a disease of stones, bones, and abdominal groans” to remind
physicians to consider this diagnosis in patients with varied complaints. With time,
the triad of St. Goar has been extended to include other nonspecific regional
symptoms of hypercalcemia pertaining to the abdomen, kidney, bone, constitutional,
.( and neurologic manifestations (Fig. 36-47
Over half of all patients diagnosed with primary hyperparathyroidism are
asymptomatic, and the disease is discovered by routine serum chemistry analysis
showing hypercalcemia. After successful surgical management of primary
hyperparathyroidism, nearly all patients realize that they had in fact been
. symptomatic
Evaluation
The diagnosis of primary hyperparathyroidism is most commonly one of exclusion. It
is most commonly considered when serum chemistry analysis reveals hypercalcemia.
A focused history in symptomatic and asymptomatic patients is important to rule out
medicinal use that might cause hypercalcemia and obscure the diagnosis—most
commonly thiazide diuretics, but also lithium and excessive ingestion of vitamin A or
vitamin D. Consumption of extraordinary amounts of milk or antacids might alert the
clinician to the diagnosis of the milk-alkali syndrome. Questions regarding renal
failure, dehydration, immobilization, and Paget's disease can lead to identifying the
cause of the hypercalcemia. Endocrine abnormalities such as adrenal insufficiency,
and either hyperthyroidism or hypothyroidism are similarly rare causes of
hypercalcemia. Granulomatous diseases such as sarcoidosis, tuberculosis,
coccidiodomycosis, histoplasmosis, and berylliosis can elevate serum calcium levels.
It is to critical to evaluate hypercalcemic patients for previous or current malignancy
with possible bony metastases. The malignant causes of hypercalcemia include renal
cell carcinoma, multiple myeloma, and squamous or small cell lung cancer. Over 90
percent of patients with hypercalcemia have primary hyperparathyroidism or
malignancy, most commonly metastatic from the prostate or breast, as the source of
. their elevated serum calcium levels
A family history of multiple endocrine neoplasia or benign familial hypocalciuric
hypercalcemia (BFHH) is critical. MEN and BFHH usually occur in younger patients
with a known genetic predisposition. BFHH involves sufficient retention of calcium
to cause hypercalcemia. Unlike patients with primary hyperparathyroidism, BFHH
patients have unusually low urinary calcium excretion. Cervical exploration in these
. patients is of no benefit and is contraindicated
Physical examination of patients with primary hyperparathyroidism is rarely of
diagnostic aid, but it is important to assess for neck masses, voice abnormalities or
hoarseness, cervical lymphadenopathy, and mobility of the cervical spine. Neck
masses most commonly represent benign thyroid nodules but could be the rare
parathyroid cancer. Hypercalcemia coupled with a firm cervical mass with hoarseness
or a recent change in voice would indicate involvement of a recurrent laryngeal nerve
secondary to this rare malignancy. As a corollary, parathyroid adenomas, regardless
of their size, are rarely palpable. While cervical lymphadenopathy can be observed
with parathyroid carcinoma, this finding would more likely represent a recent upper