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9Eurasian Medical Journal, September 2021; number №4 www eamj-ism com
UDC: 616.447-089.87
CLINICAL CASE RARE COMBINATIONS PRIMARY HYPERPARATHYROIDISM WITH DEFICIENCY OF
VITAMIN D
Sultanalieva R.B., Knyazeva V.G., Kudaibergenova N.T. International Higher School of Medicine, Bishkek, Kyrgyz Republic
Abstract
Primary hyperparathyroidism is a rare but interesting pathology that affects not only the parathyroid glands, but also bones, kidneys, and other organs. This pathology is rarely diagnosed at an early stage. We have given an example of an unusual combination ofprimary hyperparathyroidism and vitamin D deficiency.
Key words: Parathyroid gland, vitamin D, hormones, calcium.
УДК: 616.447-089.87
БАШТАПКЫ ГИПЕРПАРА ТИРОИДОЗДУН D-ВИТАМИНДИН КЕМЧИЛИГИ МЕНЕН СЕЙРЕК КОМБИНАЦИЯСЫНЫН КЛИНИКАЛЫК ИШИ
Султаналиева Р.Б., Князева В.Г., Кудайбергенова Н.Т. Медицинанын эл аралык жогорку мектеби, Бишкек, Кыргыз Республикасы
Аннотация
Баштапкы гиперпаратиреоз - сейрек кездешYYЧY, бирок кызыктуу патология, ал паратироид бездерине эле эмес, сеектерге, бейректерге жана башка органдарга да таасир этет. Бул патологияга алгачкы стадияда сейрек диагноз коюлат. Биз баштапкы гиперпаратиреоз менен Д витамининин жетишсиздигинин адаттан тыш айкалышын мисал келтирдик. Ачкыч свздвр: Калкан сымал без, D витамини, гормондор, кальций.
УДК: 616.447-089.87
КЛИНИЧЕСКИЙ СЛУЧАЙ РЕДКОГО СОЧЕТАНИЯ ПЕРВИЧНОГО ГИПЕРПАРАТИРЕОЗА С ДЕФИЦИТОМ
ВИТАМИНА D
Султаналиева Р.Б., Князева В.Г., Кудайбергенова Н.Т. Международная высшая школа медицины, Бишкек, Кыргызская Республика
Address for Correspondence:Ph.D., Knyazeva V.G .: +996 777 14 11 60, e-mail: peach.lis.87@mail.ru
Eurasian Medical Journal, Septem6er 2021; num6er №4
www.eamj-ism.com
Аннотация
Первичный гиперпаратиреоз-эторедкая, но интересная патология, которая затрагивает не только паращитовидные железы, но так же кости, почки и другие органы. Данная патология редко диагностируется на раннем этапе. Нами приведен пример необычного сочетания первичного гиперпаратиреоза и дефицита витаминаD.
Ключевые слова. Паращитовидная железа, витамин D, гормоны, кальций.
Introduction
It is now generally accepted that primary hyperparathyroidism (PHPT) is a common disease (affecting 0.05-0.1% of the population). The cause of PGPT is adenoma of the parathyroid gland (PS), which has become more common in the practice of doctors in Kyrgyzstan. Adenoma independently and uncontrollably produces parathyroid hormone (PTH), which leads to the appearance of cysts and tumor-like formations in the bone tissue, followed by its disintegration and the development of bone fractures. These changes are sometimes mistaken for tumors or tumor metastases to bone tissue [1, 2]. Normally, PTH can increase with a lack of calcium and / or vitamin D, which activates the processes of bone tissue renewal, inhibits increased bone resorption. A number of long-term and large-scale studies have shown that vitamin D deficiency or its insufficiency can lead to the development of tumors of the OR - adenomas, which are formed due to a decrease in the inhibitory effect of vitamin D on cell division of this organ, as well as due to the stimulating effect of low blood calcium levels on this the same process [3].
Goal and tasks
Using the example of a clinical situation, show the importance of awareness of doctors of all specialties about rare forms of diseases of the parathyroid gland.
Materials and methods
We present a clinical case of late diagnosis of a severe form of PGPT in combination with a vitamin D deficiency, with a long-term erroneous diagnosis of an unrecognized tumor with damage to bone tissue, which led to unjustified medical manipulations and the development of severe complications.
Results
Patient A.A., born in 1990, turned to the Bishkek Endocrinological Dispensary in October
2017 with complaints of severe pain in the legs, muscle weakness, lameness, which worsened after childbirth. The above complaints have appeared in recent years (2015-2016). From the anamnesis -heredity for endocrine diseases is not burdened. In March 2017, during pregnancy, with a minor injury, she received a fracture of the upper third of the right thigh, and was in the traction for 20 days. On March 27, the delivery was carried out by cesarean section. Subsequently, the patient underwent instrumental examinations. X-ray of bones: data for metastatic lesions of the ribs, pelvic bones, fracture of the right femur. When a computer tomography of the pelvis revealed diffuse changes of bone osteoporosis type with multiple foci osteodestruktsii and pathological fracture of the proximal upper third of the right femur. After consultation with an oncologist, the diagnosis was made: metastases to the bone tissue of the skeleton from an undetected primary focus of TxNxM1 IVst, complicated pathological fracture of the upper third of the right femur. Bone biopsy was performed, the conclusion was obtained: giant cell tumor, no malignant growth. The patient was prescribed therapy aimed at reducing bone resorption, as well as symptomatic therapy. Despite this, the patient's condition continued to worsen, bone pain and muscle weakness increased , she stopped walking, and movement became impossible without a wheelchair. The survey was continued. Ultrasound of the kidneys showed echographic signs of urolithiasis, diffuse changes in the renal parenchyma on both sides, and moderate renal pyelectasis. A general blood test revealed anemia (Hb-99 g / l, er-3.4x10 A 12 / l, ESR 25 mm / h), total calcium and blood creatinine were within the normal range (2.3 mmol / l and 48 , 9 |mol / L). The general analysis of urine revealed moderate proteinuria, leukocyturia (relative density - 1008, protein - 0.05 g / l, flat epithelium - 8-12-15, leukocytes - 6-8-12). Further examination revealed an increase in blood
Eurasian Medical Journal, September 2021; num6er №4
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PTH levels up to 2811 pg / ml (with a norm of 15-65) and osteocalcin> 100 ng / ml (14-43), although the content of ionized calcium remained within the normal range - 1.45 mmol / L (1 , 12-1.32).
On August 22, 2017, MRI of the ORS was performed - in the projection of the right parathyroid gland, an additional mass 12.3x14.2x21.6 cm in size was revealed, which indicated that PGPT required urgent surgical treatment.
6.09.17 the operation was performed: parathyroidectomy with hemithyroidectomy on the right. On histology: mixed cell adenoma of the parathyroid gland. Thus, it was confirmed that the patient had primary hyperparathyroidism, osteo-visceral form, severe course, with the presence of g ene ral iz e d s eve re hyp e rp arathyro id osteodystrophy, urolithiasis. After the operation, the patient's condition began to improve, pain in the bones and joints decreased . However, symptoms of postoperative hypothyroidism (TSH - 10.3 mlU / L) and signs of hypocalcemia (ionized calcium - 1.08 mmol / L / L) with convulsive syndrome developed (since the patient did not use calcium preparations prescribed by a doctor). Subsequently, a correction was carried out and replacement therapy with calcium and thyroid hormones was prescribed. But despite the ongoing therapy, the patient continued to have general weakness and difficulty in walking, and therefore continued to use a wheelchair. Dynamic examination revealed: a low content of vitamin D -34.49 nmol / l (50.0-80.0) and a high level of parathyroid hormone - 351.4 pg / ml (9.5-75). Taking
into account these data, the treatment was corrected, the following drugs were prescribed: vitamin D (aquadetrim 14 caps 1 time per day), calcium preparations (when converted to elemental calcium -1800 mg / day), levothyroxine - 50 |g / s.
In March 12.03.18, a repeated examination revealed an improvement in her condition, there was no muscle weakness, the patient stopped using a wheelchair, and moved on her own with crutches. Revealed positive dynamics in the previously changed biochemical parameters: vitamin D - 86.18 nmol / l (50.0-80.0); parathyroid hormone - 9.92 (N 1.58-6.8); inorganic phosphorus - 0.70 mmol / l (0.48-2.20); ionized calcium - 1.23 (1.12-1.32); TSH - 5.1 mlU / L (0.4-4.00). The patient was recommended to continue treatment under the supervision of an endocrinologist.
Conclusion. This clinical case is one of the few examples of an extremely severe course of the manifest form of primary hyperparathyroidism in combination with a vitamin D deficiency, with an erroneous diagnosis of bone tissue tumors, which led to unjustified medical manipulations and unsubstantiated treatment.
Referents
1. Dedova I.I., Melnichenko G.A. Endocrinology. National leadership. Short edition / ed. I.I.Dedova, G.A.Melnichenko. - M.: GEOTAR - Media, 2013 .-- 752 p.
2. Internal medicine according to Tinsley R. Harrison // Practice - M., 2002.
3. Harris SS, Soteriades E, Coolidge JA, Mudgal S, Dawson-Hughes B. Vitamin D insufficiency and hyperparathyroidism in a low income, multiracial, elderly population. J Clin Endocrinol Metab 2000; 85: 4125-30.
