Joseph L. Shaker

Secondary hyperparathyroidism and osteopenia in women following gastric exclusion surgery for obesity

Gastric exclusion has been introduced as a surgical treatment for morbid obesity. We describe two women who had undergone gastric bypass for obesity with metabolic bone disease and secondaryhyperparathyroidism. In one patient transiliac bone biopsy after double tetracycline labelling demonstrated histologic evidence of hyperparathyroidism with osteitis fibrosa cystica. Six additional women who had undergone gastric exclusion were evaluated. Serum phosphorus, calcium, and creatinine were normal in all but one patient who had hypocalcemia. Serum immunoreactive parathyroid hormone was elevated in seven of eight patients and urinary calcium was ≤2 mmol/d (80 mg/24 h) in 6 patients. Lumbar spine bone mineral density was 86±7 (mean±SE) per cent of predicted and femoral neck bone mineral density was 89±6 per cent of predicted. Women who have had gastric exclusion for obesity may develop secondary hyperparathyroidism which could result in loss of bone mass.

Case report: hypercalcemia with inappropriate 1,25-dihydroxyvitamin D in Wegener's granulomatosis.

Hypercalcemia associated with the extrarenal production of 1,25-dihydroxyvitamin D (1,25(OH)2D) has been reported in several disorders, most notably granulomatous diseases such as sarcoidosis. The authors describe a woman with hypercalcemia, renal insufficiency, microscopic hematuria, and anemia. The circulating 1,25(OH)2D level was higher than appropriate for the ambient conditions (renal insufficiency, suppressed intact parathyroid hormone, and hypercalcemia). A kidney biopsy was consistent with Wegeners granulomatosis, and treatment with prednisone and cyclophosphamide was associated with normalization of serum calcium levels, improved renal function, a marked decrease in serum 1,25(OH)2D levels, and increased serum intact parathyroid hormone levels. These findings are consistent with the unregulated production of 1,25(OH)2D by inflammatory cells associated with Wegeners granulomatosis.

Successful Treatment of Tumor-Induced Osteomalacia with CT-Guided Percutaneous Ethanol and Cryoablation

CONTEXT Tumor-induced osteomalacia is a rare condition usually caused by benign mesenchymal tumors. When the tumor can be found, patients are usually managed by wide excision of the tumor. OBJECTIVE We report a 51-yr-old male with clinical and biochemical evidence of tumor-induced osteomalacia caused by a mesenchymal tumor in the right iliac bone. He declined surgery and appears to have been successfully managed by computed tomography-guided percutaneous ethanol ablation and percutaneous cryoablation. RESULTS Our patient appears to have had an excellent clinical and biochemical response to computed tomography-guided percutaneous ethanol ablation and percutaneous cryoablation. We found one prior case of image-guided ablation using radiofrequency ablation for tumor-induced osteomalacia. CONCLUSIONS Although the standard treatment for tumor-induced osteomalacia is wide excision of the tumor, image-guided ablation may be an option in patients who cannot have appropriate surgery or who decline surgery.

Recent developments in osteogenesis imperfecta

Osteogenesis imperfecta (OI) is an uncommon genetic bone disease associated with brittle bones and fractures in children and adults. Although OI is most commonly associated with mutations of the genes for type I collagen, many other genes (some associated with type I collagen processing) have now been identified. The genetics of OI and advances in our understanding of the biomechanical properties of OI bone are reviewed in this article. Treatment includes physiotherapy, fall prevention, and sometimes orthopedic procedures. In this brief review, we will also discuss current understanding of pharmacologic therapies for treatment of OI.

Acute extracapsular parathyroid hemorrhage: case report and review of the literature.

OBJECTIVE To describe a patient with extracapsular parathyroid hemorrhage and review the signs and symptoms of this condition. METHODS We report a case of extracapsular parathyroid hemorrhage in a patient with primary hyperparathyroidism and present an overview of previously reported cases. RESULTS A 48-year-old woman with documented primary hyperparathyroidism, who was awaiting surgical intervention, had acute onset of a neck mass, neck pain, and dysphagia. She was found to have sustained a spontaneous extracapsular hemorrhage of a parathyroid adenoma. Hypercalcemia persisted, and she subsequently underwent curative parathyroidectomy for the primary hyperparathyroidism. We also identified 15 previously reported cases of extracapsular parathyroid hemorrhage and summarized the most common manifestations-most notably, a neck mass or swelling, ecchymoses of the neck and chest, dysphagia, neck pain, hoarseness, and dyspnea. CONCLUSION Clinicians should be aware of the potential for occurrence of extracapsular parathyroid hemorrhage in patients with primary hyperparathyroidism. When this condition occurs, severe hypercalcemia or acute hypocalcemia may be present. Hypercalcemia is often persistent; however, autoinfarction of the parathyroid adenoma is possible.

Case Report: Renal Phosphate Wasting, Syndrome of Inappropriate Antidiuretic Hormone, and Ectopic Corticotropin Production in Small Cell Carcinoma

Renal phosphate wasting related to a tumor (oncogenous osteomalacia) is a rare disorder usually associated with benign mesenchymal tumors. In this article, the authors describe a man with renal phosphate wasting and the syndrome of inappropriate antidiuretic hormone associated with small cell carcinoma. Chemotherapy markedly reduced tumor burden and was associated with normalization of renal phosphate handling and serum sodium. With recurrence, renal phosphate wasting and the syndrome of inappropriate antidiuretic hormone developed again, with the additional complication of hypercortisolism secondary to ectopic corticotropin production. The authors report the rare occurrence of renal phosphate wasting with small cell carcinoma (5 previously reported cases) and the unique co-existence of this paraneoplastic syndrome with the syndrome of inappropriate antidiuretic hormone and ectopic corticotropin production.

Artifactual Reduction in Bone Density as a Result of Technetium-99m MDP for Bone Scanning: Report of Two Cases

We present two patients in whom marked changes in dual-energy X-ray absorptiometry (DXA)-measured bone mineral density were found to be the result of prior administration of technetium-99m methylene diphosphonate (MDP) for bone scanning. In patient 1, an artifactual 50% decrease in lumbar spine and 19% decrease in left total hip bone density over a 14-mo period was the result of technetium-99m injection 3 h before the second bone density measurement. In patient 2, a dramatic increase in bone density at 6 mo was the result of artifactual reduction in bone density on the baseline study as a result of technetium-99m injection 2 h earlier. Clinicians and technologists should be aware that technetium-99m used for bone scanning could cause artifactual reduction in DXA-measured bone mineral density.

Coccidioidomycosis-induced Thyroiditis and Calcitriol-mediated Hypercalcemia in a Heart Transplantation Patient

A 56-year-old man with a history of cardiac transplantation developed disseminated coccidioidomycosis involving the upper extremities. Suppression of thyrotropin was followed by marked biochemical hypothyroidism. Biopsy of an enlarged left thyroid lobe demonstrated infiltration with coccidioidomycosis. He also developed hypercalcemia thought to be mediated by 1,25-dihydroxyvitamin D and was treated with a bis-phosphonate. This rare case of disordered calcium metabolism and thyroiditis should alert physicians of the potential endocrinopathies that can develop in patients who have undergone solid organ transplantation.

Endocrine Manifestations of Celiac Disease

Celiac disease is a disorder resulting from exposure of predisposed individuals to certain grain proteins and is associated with many autoimmune endocrine disorders. This condition may occur with classic symptoms of malabsorption or with minimal or no gastrointestinal symptoms. Patients may present with hypocalcemia, osteoporosis, or osteomalacia. Because of decreased intestinal absorption of levothyroxine, celiac disease may present with excessive levothyroxine requirements in hypothyroid patients. Furthermore, celiac disease is seen in increased frequency in patients with type 1 diabetes mellitus and should strongly be considered in the differential diagnosis of diarrhea or weight loss in patients with type 1 diabetes mellitus. This article describes the authors’ experience with celiac disease and emphasizes the ways it may present to clinical endocrinologists.

Osteomalacia with hypophosphatemia and hypercalciuria: A possible new variant of osteomalacia

A 12-year-old girl had a severe genu valgum deformity and osteomalacia with hypophosphatemia, hypercalciuria, and modestly elevated levels of 1,25-dihydroxyvitamin D3 and intact parathyroid hormone. This patient seems to have a different type of hypophosphatemic osteomalacia from that previously described.