Why is my Hyperparathyroid Patient Itching?
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”FIRST AND FINEST” Why is my Hyperparathyroid Patient Itching? LCDR Amie Harvey, MD LCDR Karen Kaufman, DO CDR Jason Daily, MD Naval Medical Center Portsmouth
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Why is my Hyperparathyroid Patient Itching?. LCDR Amie Harvey, MD LCDR Karen Kaufman, DO CDR Jason Daily, MD Naval Medical Center Portsmouth. Disclaimer. Nothing to disclose - PowerPoint PPT Presentation
Transcript of Why is my Hyperparathyroid Patient Itching?
”FIRST AND FINEST”
Why is my Hyperparathyroid Patient Itching?
LCDR Amie Harvey, MD
LCDR Karen Kaufman, DO
CDR Jason Daily, MD
Naval Medical Center Portsmouth
”FIRST AND FINEST”
Disclaimer• Nothing to disclose• The views expressed in this presentation are
those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.
”FIRST AND FINEST”
Subjective• 37 year old female with 2 week history of
itchy rash• Fatigue, headaches, nausea, decreased
appetite, constipation
”FIRST AND FINEST”
Medical History• No history of medical problems• No known allergies• No family history of thyroid or parathyroid
disease• No tobacco, alcohol or illicit drug use• No current medications
”FIRST AND FINEST”
Physical Exam• Afebrile; HR 82; BP 125/86; RR 14 • Skin with erythematous, edematous
wheals without central pallor on lower back, chest and upper extremities without facial, periorbital or mucosal swelling
• Thyroid without diffuse enlargement or palpable nodules
• No lymphadenopathy
”FIRST AND FINEST”
Skin Findings
”FIRST AND FINEST”
Laboratory ResultsComplete Blood Count
WBC / mcL 6,000
HgB g/dL 14.1
HCT (%) 41.5
PLT/mcL 188,000
Neutrophils (%) 72.4
Lymphocytes (%) 21.9
Eosinophils (%) 0.0
Basic Metabolic Panel
Na (mmol/L) 141
K (mmol/L) 4.2
Cl (mmol/L) 105
CO2 (mmol/L) 25
BUN (mgl/dL) 12
Cr (mg/dL) 0.8
Ca (mg/dL) 11.4 ♦
”FIRST AND FINEST”
Laboratory Results
Additional Labs
Parathyrin Hormone (pg/mL) 136 ♦ (10-65)
Vitamin D, 25 Hydroxy (ng/mL) 57.3 (30-100)
24 h urine calcium (mg/24h) 366♦ (100-300)
FECA 1.62% ♦Ca ionized (mmol/L) 1.45 ♦ 1.16-1.32
Thyroglobulin AB (IU/mL) <20 <20
Thyroperoxidase AB (IU/mL) 14 <35
Environmental Allergens sIgE Negative
CU index (histamine%) 69 ♦ (<16)
”FIRST AND FINEST”
”FIRST AND FINEST”
”FIRST AND FINEST”
Diagnosis and Treatment
• Primary Hyperparathyroidism (PHP)– Treatment: Surgical excision
• Chronic Urticaria (CU)– H1 and H2 Antihistamines
”FIRST AND FINEST”
Pathology• 1.2 gram, 3 x 0.9 cm homogenous, light tan
inconspicuous capsule
Parathyroid Adenoma 10x H&E Parathyroid Adenoma 40x H&E
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PHP• Demographics
– Prevalence 1: 1000– More common in
women (2:3)– Most common in 5th or
6th decade
• Symptoms– Skeleton, cortical bone– Nephrolithiasis– Chronic pancreatitis– Polyuria– Polydipsia– Anorexia– Hypertension– Nausea– Vomiting
”FIRST AND FINEST”
CU• Daily, near daily, greater than 6 weeks• Self limited in most patients
– Average duration is 2-5 years– Spontaneous remission at one year for 30%– Persists greater than 5 year in 20%
• Strong Association with Autoimmune disease
Sarbjit S. Saini, Middleton’s Allergy: Principles and Practice 8th edition, 2013: 575-587.Kulthanan K, et al. J Dermatol 2007; 34:294-301.
Kozel MM, et al. J Am Acad Dermatol 2001; 45:387-391.
Toubi E, et al. Allergy 2004; 59:869-873.
”FIRST AND FINEST”
Cutaneous Associations
• Multiple Endocrine Neoplasia Type 1– Angiofibromas (85%)– Collagenomas (70%)– Lipomas– Café-au-lait spots
• Multiple Endocrine Neoplasia Type 2– Cutaneous amyloidosis
• Sporadic Hyperparathyroidism– Metastatic calcification
Fuleihan GE et al : Clinics in Dermatology 2006; 24; 281-288
”FIRST AND FINEST”
PHP and Urticaria
• PHP– Parathyroid hyperplasia (1 case)– Parathyroid Adenoma (3)
• 1st reported case of PHP with urticaria– Reported in JAMA 1983 in 58 year old female
with 1 year of urticaria– 4 gram adenoma
Liechty DR, Firminger HI: JAMA 1983; 250:789-790.
”FIRST AND FINEST”
Previous Theories• 1983 JAMA – “circulating antigen antibody
complexes”– Similar to other necrotic cancers– Hemorrhagic areas, cyst formation, and fibrosis
induce antigen formation• Hypercalcemia
– Induces mast cell degranulation – Induces histamine release
• Calcium infusion did not reproduce urticaria• Urticaria not present in other cases of hypercalcemia
Liechty DR, Firminger HI: JAMA 1983; 250:789-790.
”FIRST AND FINEST”
Subtypes
Urticaria25%
Chronic Urticaria
Chronic Idiopathic
Urticaria (CIU)
Physical Urticaria
Chronic Autoimmune
Urticaria (CAU)
Systemic Disease
Malignancy
Acute Urticaria
EAACI/GA2LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria, Allergy 2009: 64:1417-1426.
”FIRST AND FINEST”
• Persuasive, but not conclusive evidence for the existence of autoimmune chronic spontaneous urticaria was found by a European taskforce panel 2013
Konstantinou GN, Asero R, Ferrer M, et al. EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria. Allergy 2013;68: 27
”FIRST AND FINEST”
CAU Testing• 1986 Autologous Serum Skin Test (ASST)
– Administration and interpretation not standardized
• CU Index testing
Cho , altrich et al. Ann Allergy Asthma Immunol 2013; 110: 29-33.
”FIRST AND FINEST”
CU Index Test• Donor basophils combined with:
– patient’s serum– buffer control – anti-IgE
• Alliquots of cells lysed for histamine content
• Histamine release is measured and compared with total histamine in basophils
Cho , altrich et al. Ann Allergy Asthma Immunol 2013; 110: 29-33.
”FIRST AND FINEST”
CAU
• <img height="1" width="1" src="http://usadmm.dotomi.com/v?dtmid=475702197181741608&magic=42&comId=2206&msgCampId=77419&trid=245902528404169869&tid=78231&etype=91&edtl=12"/>
• Medical Websites• Medical info• http://www.colorectaltumor.com• http://www.genitaldischarge.com• http://www.hepaticcarcinoma.com• http://www.hpvvaccination.com• http://www.ovarydisease.com
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Becky M, et al. Current Allergy and Asthma Reports 2005; 5:270-276.
”FIRST AND FINEST”
Follow up Testing
Postoperative
Calcium 9.0
Parathyroid Hormone
26
CU Index < 16 (negative)
Preoperative
Calcium 11.4 ♦
Parathyroid hormone
136 ♦
CU Index 69 ♦
”FIRST AND FINEST”
Our Case• Resolution of urticaria after adenoma
excision• Resolution of positive index supports IgG
against IgE or IgE receptor is stimulated by parathyroid adenoma
• Further studies of possible subclinical antibody presence in PHP warranted
”FIRST AND FINEST”
Questions?
Thank you.
