A 37 year old female presents to her physician’s office with acute pain over her
ID: 3164682 • Letter: A
Question
A 37 year old female presents to her physician’s office with acute pain over her right flank and persistent abdominal pain. Additionally, she reports a 2 year history of generalized fatigue and depression associated with difficulty concentrating and significant mood swings. She has no history of drug or alcohol use and no significant family history. Following ultrasound examination she is diagnosed with a kidney stone. Laboratory tests of serum parathyroid levels reveal an abnormally high parathyroid hormone concentration of 125 pg/mL. The patient is further diagnosed with hyperparathyroidism and it is determined that exploratory surgery is needed. Once the parathyroid glands have been exposed they are visually and physically examined. On palpation a small mass is found on the right inferior parathyroid gland and removed. Parathryoid hormone levels were monitored until returning to normal limits.
Guiding Questions
A 37 year old female presents to her physician’s office with acute pain over her right flank and persistent abdominal pain. Additionally, she reports a 2 year history of generalized fatigue and depression associated with difficulty concentrating and significant mood swings. She has no history of drug or alcohol use and no significant family history. Following ultrasound examination she is diagnosed with a kidney stone. Laboratory tests of serum parathyroid levels reveal an abnormally high parathyroid hormone concentration of 125 pg/mL. The patient is further diagnosed with hyperparathyroidism and it is determined that exploratory surgery is needed. Once the parathyroid glands have been exposed they are visually and physically examined. On palpation a small mass is found on the right inferior parathyroid gland and removed. Parathryoid hormone levels were monitored until returning to normal limits.
Answer the questions below.
1. Given what you know about the function of the parathyroid gland what is another substance in the blood serum that you would expect to be outside of normal limits?
2. Predict which muscular structures the surgeon needs to reflect or cut to reach the parathyroid glands from an anterior midline approach. Identify which vascular and nervous structures will need to identified and avoided to prevent injury. If you need help visualizing this, Biodigital is a great tool to utilize.
3. What are the upstream regulators of parathyroid function? In other words, what is the normal flow of information to either stimulate or suppress parathyroid function?
4. What are the downstream effectors that the parathyroid hormone acts on? How does this explain the symptoms our patient presented with?
Explanation / Answer
1. Blood calcium levels whould be higher than normal limits (More than 1 mg/dL) in Hyperparathyroidism
Apart from blood serum levels, there is marked hypercalciurea (more than 400mg/day), Creatinine clearance is less than 30% of normal, Bone Density reduction with T score less than 2.5 are the characteristic features of Hyperparathyroidism.
2. Internal jugular vein is to be first exposed and retracted laterally. Carotid artery and Recurrent Laryngeal nerve are to be identified and protected to prevent injury.
3. The chief cells which secrete Parathormone are sensitive to extracellular cacium concentrations. Low level of calcium ions in the blood stimulates the Gprotein in cheif cell which releases calcium ions from endoplasmic reticulum that inturn liberates Parathormone from the chief cells of Parathyroid glands.
4. The downstream effectors of Parathormone are
i. Osteoclasts (whose activity and number are increased by Parathormone) which is responsible for bone remodelling, raises blood calcium levels of by increasing the release of calcium from bones (through Parathormone receptors in bone). Calcitonin suppresses the activity of parathormone
ii. Stimulates reabsorption of Calcium by kidneys by acting on proximal convoluted tubule, thick ascending limb, distal convoluted tubule of nephron
Excess blood calcium resulted in formation of renal calculi (kidney stones). This would be the explanation for pain in flanks and abdominal pain which is radiating from the source of kidney and spread.
Since calcium is a second messenger for:
Calcium is a second messenger which is involved in the physiological roles like:
1. Contraction of muscles by binding to troponin: Responsible for fatigue due to more muscle contraction
2. Neuronal Transmission
3. Motility through Flagella and cilia
4. Cell growth and Proliferation: General body pains and fatigue
5. Neurogenesis
6. Synaptic plasticity: This could be the possible explanation for mood swings and depression
7. Apoptosis
8. Cell adhesion to extracellular matrix
9. Activation of T lymphocytes and B Lymphocytes
About parathyroid gland : Parathyroid glands are two pairs of endocrine glands present on thyroid gland which is responsible for the production of parathormone (PTH). Hyperparathyroidism results in increased levels of parathormone that increases the levels of calcium in blood.