Primary Hyperparathyroidism

What Is Primary Hyperparathyroidism?

[dropcap]P[/dropcap]rimary hyperparathyroidism is a parathyroid disorder characterized by excessive secretion of parathyroid hormone by one or more parathyroid glands for more than 6 months.

In primary hyperparathyroidism, blood calcium levels are high while phosphorus levels are decreased due to the action of parathyroid hormone.

Parathyroid hormone is produced by the four pea sized parathyroid glands that are located on the thyroid gland in the front of the neck. Partly because the thyroid and parathyroid glands share the same anatomic place in the body and partly because they have similar names, they are often confused although they have completely different actions.

Parathyroid hormone normally keeps calcium and the opposing mineral phosphorus levels in balance by drawing calcium as needed from bones to increase it in blood and releasing excess phosphorus through the kidneys to decrease blood levels.

Primary hyperparathyroidism is commonly caused by an adenoma (tumor) in a parathyroid gland (80%) or 15% due to hyperplasia of gland tissue (overgrowth). It is seldom associated with autoimmune disorders. However, cancer is a  possibility.

Q: What is a parathyroid adenoma?

A: A parathyroid adenoma is usually a solitary, well circumscribed, soft, tan reddish-brown nodule with a capsule. Gland tissues outside of the adenoma are normal or slightly shrunken (not needed anymore).¹

Untreated, primary hyperparathyroidism results in cyst formations in bone marrow (osteitis fibrosa cystica) and brown tumors in bone tissue. Cysts contain large amounts of fibrous tissue with areas of hemorrhage. Brown tumors contain aggregates of osteoclasts (bone cells), hemorrhage and giant cells resembling neoplasms.²

Here is the symptomatolgy: “Painful Bones, Renal Stones, Abdominal Groans, and Mental Moans.”

What Is Primary Hyperparathyroidism In Celiac Disease and/or Gluten Sensitivity?

• Primary hyperparathyroidism is an associated disorder of celiac disease.
• The presence of normocalcemia (normal calcium blood level) in primary hyperparathyroidism should prompt the physician to look for vitamin D deficiency and to rule out intestinal malabsorption.³,⁴

How Prevalent is Primary Hyperparathyroidism In Celiac Disease and/or Gluten Sensitivity?

Primary hyperparathyroidism has small risk in patients with untreated celiac disease that was found to be 68 persons with celiac disease out of 17,121. The excess risk disappeared after more than 5 years of follow-up.⁵

What Are The Symptoms Of Primary Hyperparathyroidism?

Primary hyperparathyroidism is marked by these symptoms:⁶

• Anorexia.
• Nausea.
• Constipation.
• Pancreatitis.
• Gallstones.
• Weight loss.
• Muscle weakness.
• Fatigue.
• Confusion.
• Depression.
• Bone pain.
• Osteopenia.
• Osteomalacia.
• Kidney stones.
• Osteitis fibrosa may develop when severe.
• May cause calcifications on heart valves (aortic or mitral).

How Does Primary Hyperparathyroidism Develop In Celiac Disease and/or Gluten Sensitivity?

• Primary hyperparathyroidism results from adenoma (benign tumor) in most cases, advanced secondary hyperparathyroidism in celiac disease and malabsorption of vitamin D.

Does Primary Hyperparathyroidism Respond To Gluten-Free Diet?

Yes. Celiac disease-related primary hyperparathyroidism responds to gluten free diet containing adequate vitamin D. Supplementation with vitamin D may be required.⁶

6 Steps To Improve Primary Hyperparathyroidism In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both parathyroid and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications deplete vitamin D that can cause primary hypoparathyroidism. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

 ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Vitamin D.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Vitamin D.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Vitamin D.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin D.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin D. [/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Vitamin D3 as prescribed following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Primary Hyperparathyroidism In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Primary hyperparathyroidism and celiac disease: a population-based cohort study.” The aim of the study was to examine the risk of PHPT in patients with celiac disease found that celiac disease patients are at increased risk of PHPT, but the absolute risk is small, and the excess risk disappeared after more than 5 years of follow-up.

Researchers identified 17,121 adult patients with celiac disease who were diagnosed through biopsy reports (Marsh 3, villous atrophy) from all 28 pathology departments in Sweden. Biopsies were performed in 1969-2008, and biopsy report data were collected in 2006-2008. Statistics Sweden then identified 85,166 reference individuals matched with the celiac disease patients for age, sex, calendar period, and county.During follow-up, 68 patients with celiac disease and 172 reference individuals developed PHPT. The absolute risk of PHPT was 42/100,000 person-years with an excess risk of 20/100,000 person-years. The risk increase for PHPT only occurred in the first 5 yr of follow-up.⁹

CASE REPORT SUMMARIES

“Irreversible end-stage heart failure in a young patient due to severe chronic hypocalcemia associated with primary hypoparathyroidism and celiac disease.” This case report describes diagnosis of celiac disease upon finding hypocalcemia and primary hypoparathyroidism in a 39-year-old male who was admitted to the emergency room with acute retrosternal pain and dyspnea (shortness of breath). He exhibited severe hypocalcemia and acute renal failure. High creatine kinase (CK) levels did not correlate with biomarkers of myocardial necrosis (negative troponin test, heart type creatine kinase isoenzyme (CK-MB) < 1% of CK value). The ECG showed an extremely long QT interval (0.6 sec) and T-wave inversions on V(4) through V(6). The left ventricular ejection fraction (LVEF) was as low as 25%, while coronary angiography was normal. Investigation of the hypocalcemia revealed primary hypoparathyroidism (Parathyroid hormone (PTH) < 3 pg/ml) and concomitant celiac disease with positive antigliadin and endomysial antibodies. The cardiovascular episodes and the dilated heart failure were attributed to the chronic hypocalcemia since no other cause was found. The correction of hypocalcemia has not been sufficient to reverse the end-stage heart failure after more than 6 months of treatment, even though ECG abnormalities have receded, implying permanent cardiac impairment.

This case demonstrates an unusual clinical condition where 2 calcium homeostasis disorders led to severe hypocalcemia with clinical manifestations of end-stage heart failure. The severe cardiac failure appeared to be nonreversible after calcium repletion suggesting permanent cardiac muscle dysfunction due to associated cardiomyopathy.¹⁰

“Severe primary hyperparathyroidism masked by asymptomatic celiac disease.” This case report describes the presence of asymptomatic celiac disease as the underlying cause of  severe primary hyperparathyroidism in a 24-year-old woman who had a normal calcium blood level on presentation.

The patient presented with a 5-year history of generalized weakness, which had progressed until use of a wheelchair became necessary. She also had sustained low-trauma fragility fractures of the right tibia and left femur. She had no symptoms suggestive of celiac disease. Physical examination revealed severe proximal myopathy (arms and legs).

Laboratory data (and reference ranges) were as follows: serum calcium, 2.34 mmol/L (2.1 to 2.6); phosphorus, 0.91 mmol/L (0.90 to 1.50); alkaline phosphatase, 421 U/L (40 to 135); albumin, 37 g/L (35 to 45); parathyroid hormone, 874 ng/L (15 to 65); urine calcium, 3.76 mmol/d (2.5 to 8); and 25-hydroxyvitamin D, <13 nmol/L (22 to 116). She was treated with increasing doses of calcitriol, ergocalciferol, and calcium carbonate, but the serum calcium concentration did not increase substantially (reaching a maximum of 2.70 mmol/L on suprapharmacologic doses of these agents). Malabsorption was considered as an explanation for this apparent resistance to these medications. The result of antibody screening for celiac disease was highly positive, and a distal duodenal biopsy confirmed the diagnosis of celiac disease . A technetium Tc 99m sestamibi scan revealed uptake in the neck that was consistent with a single parathyroid adenoma, which was surgically removed. Treatment with a gluten-free diet, calcium carbonate, and ergocalciferol yielded remarkable clinical, biochemical, and radiologic improvement.⁴

“Osteomalacia secondary to celiac disease, primary hyperparathyroidism, and Grave’s disease.” This case report of a 34 year old woman with severe bone deformities, severe muscle weakness and weight loss, describes finding celiac disease subsequent to revealed Grave’s disease and hypophosphatemia, normal plasma calcium levels, very low urinary calcium, and low 25-hydroxy vitamin D level. The patient underwent a near-total thyroidectomy, with removal of a parathyroid adenoma. The presence of normocalcemia (normal calcium blood level) in primary hyperparathyroidism should prompt the physician to look for vitamin D deficiency and to rule out intestinal malabsorption.⁶

Sources:

1. http://quizlet.com/32428692/pathology-of-parathyroid-and-bone-flash-cards [↩]
2. http://quizlet.com/32428692/pathology-of-parathyroid-and-bone-flash-cards/ [↩]
3. Gannage MH, Abikaram G, Nasr F, Awada H. Osteomalacia secondary to celiac disease, primary hyperparathyroidism, and Grave’s disease. American Journal of the Medical Sciences. Feb 1998;315(2):136-9. [↩]
4. Alzahrani AS1, Al Sheef M. Severe primary hyperparathyroidism masked by asymptomatic celiac disease. Endocr Pract. 2008 Apr;14(3):347-50. [↩] [↩]
5. Ludvigsson JF, Kämpe O, Lebwohl B, Green PH, Silverberg SJ, Ekbom A. Primary hyperparathyroidism and celiac disease: a population-based cohort study. J Clin Endocrinol Metab. 2012 Mar;97(3):897-904. doi: 10.1210/jc.2011-2639. Epub 2012 Jan 11. [↩]
6. Gannage MH, Abikaram G, Nasr F, Awada H. Osteomalacia secondary to celiac disease, primary hyperparathyroidism, and Grave’s disease. American Journal of the Medical Sciences. Feb 1998;315(2):136-9. [↩] [↩] [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Ludvigsson JF, Kämpe O, Lebwohl B, Green PH, Silverberg SJ, Ekbom A. Primary hyperparathyroidism and celiac disease: a population-based cohort study. J Clin Endocrinol Metab. 2012 Mar;97(3):897-904. doi: 10.1210/jc.2011-2639. [↩]
10. Mavroudis K, Aloumanis K, Stamatis P, Antonakoudis G, Kifnidis K, Antonakoudis C. Irreversible end-stage heart failure in a young patient due to severe chronic hypocalcemia associated with primary hypoparathyroidism and celiac disease. Clin Cardiol. 2010 Feb;33(2):E72-5. doi: 10.1002/clc.20512. [↩]