Sneana Marinkovi , Nenad Laketi 1

POVEZANOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE I GRA E TITASTE LEZDE NAA ISKUSTVA

Uvod

Primarni hiperparatireoidizam je generalizovani poreme aj metabolizma kalci-juma, fosfata i kostiju uzrokovan povienom sekrecijom PTH.

Cilj rada

Pokazati povezanost primarnog hiperparatireoidizma sa poreme ajem funkcije i gra e titaste lezde.

Materijal i metode

Istraivanjem je obuhva eno 33 pacijenta kojima je dijagnostikovan primarni hiperparatireoidizam u Specijalnoj bolnici igota na Zlatiboru, u periodu od 1. januara do 31. decembra 2014. godine.

Rezultati rada

Prikazana su 33 pacijenta, od kojih su 31 bile osobe enskog pola, to je 93,94%, dok su bila samo 2 mukarca, to je 6,06% uzorka.

Ultrasonografskim pregledom bubrega utvrdili smo da 40% naeg uzorka (13 pacijenata) ima bilateralnu mikrolitijazu, 6 (18%) bilateralnu kalkulozu, 3 kalkulozu levog bubrega (9%), 1 (3%) mikrolitijazu levog bubrega. Negativan nalaz ultrasono-gra je bubrega imalo je 10 pacijenata nae grupe, to je 30% uzorka.

1 Specijalna bolnica za bolesti titaste lezde i bolesti metabolizna, Zlatibor

16 MEDICINSKI GLASNIK / str. 15-16

Pregledom kotane gustine doli smo do podatka da je 17 pacijenata nae grupe (52%) imalo osteopeniju, a 16 (48%) osteoporozu.

Negativan scintigrafski nalaz paratitastih lezda (MIBI) imalo je 8 pacijena-ta.

Kod 11 pacijenata (33%) scintigra ja paratitastih lezda se u potpunosti pokla-pala sa ultrazvu nim pregledom vrata.

Poreme aj gra e titaste lezde imali su svi pacijenti nae grupe, dok je poreme aj funkcije imalo samo 6 pacijenata (18%) uzorka. Svih 6 pacijenata imalo je smanjenu funkciju titaste lezde.

Zaklju ak

Naim radom pokazali smo da je primarni hiperparatireoidizam povezan sa poreme ajem gra e, ali ne i sa poreme ajem funkcije titaste lezde.

Klju ne re i: primarni hiperparatireoidizam, kalkuloza, osteoporoza.

Sneana Marinkovi , Nenad Laketi

POVEZANOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE I GRA E TITASTE LEZDE NAA ISKUSTVA

Uvod

Primarni hiperparatireoidizam je generalizovani poreme aj metabolizma kalcijuma, fosfata i kostiju, uzrokovan povienom sekrecijom PTH (Harison, In-terna medicina, 2004). Nastaje kao posledica adenoma, hiperplazije ili karcinoma paratitastih zlezda. Adenom jedne ili vie paratitastih zlezda smatra se naj e im uzrokom ove bolesti. Naj e a lokalizacija adenoma je na donjim paratitastim lezdama. I kod adenoma i kod hiperplazije paratitastih lezda dominiraju glavne elije (Harison, Interna medicina, 2004). Oboljenje ima najve u incidencu izme u

tre e i pete decenije ivota (Harison, Interna medicina, 2004). Polovina ili ak i vie pacijenata sa primarnim hiperparatireoidizmom su asimptomatski. Asimpto-matski hiperparatireoidizam de nisan je kao dokumentovan hiperparatireoidizam bez znakova ili simptoma koji karakteriu ovu bolest (Harison, Interna medicina, 2004). Primarni hiperparatireoidizam je tre e po u estalosti endokrinoloko obo-ljenje sa najve om incidencom kod ena u postmenopauzalnom periodu (Fraser W. Hyperparathyreodismus, Lancet 2009).

Vode i znak je hiperkalcemija koja se javlja zbog pove ane resorpcije kostiju, smanjene urinarne eliminacije kalcijuma i pove ane apsorpcije u crevima. Kod ovih pacijenata javlja se i kalciurija, uz pove anu sklonost urolitijazi, zatim poliurija zbog osmotske diureze, to vodi dehidraciji i smanjenju telesne teine. Reapsorpcija fosfata u bubrezima je smanjena, to vodi hipofosfatemiji i hiperfosfaturiji. Klini ka slika zavisi od vrednosti parahormona i stepena hiperkalcemije (Catherine Cormier, et al. Primary hyperparathyreoidismus and osteoporosis in 2004).

Dijagnoza ove bolesti se postavlja na osnovu povienog nivoa PTH, povienog nivoa kalcijuma i snienog nivoa fosfata u krvi, ultrazvu nog pregleda vrata i scin-tigra je paratitastih lezda.

Poreme aj gra e titaste zlezde manifestuje se kao difuzna i nodozna struma, dok se poreme aj rada titaste lezde ogleda u smislu pove ane i smanjene funkcije, odnosno hiper i hipotireoidizma (Harison, Interna medicina 2004).

18 MEDICINSKI GLASNIK / str. 17-23

Cilj rada

Pokazati povezanost primarnog hiperparatireoidizma sa poreme ajem funkcije i gra e titaste lezde.

Materijal i metode

Istraivanjem je obuhva eno 33 pacijenta kojima je dijagnostikovan primarni hiperparatireoidizam u Specijalnoj bolnici igota na Zlatiboru, u periodu od 1. januara do 31. decembra 2014. godine. Svim pacijentima uradili smo ultrasonografski pregled vrata i bubrega, na ultrazvu nom aparatu General Electric LogiQ 3, Dexa pregled na Hologic Explorer osteodenzitometru, scintigra ju paratitastih zlezda (MIBI, 99 M Tehnecium), na Simens Orbiter Gama kameri, hormonski status titaste lezde, metodom hemiluminiscencije na DPC aparatu, kao i nivo kalcijuma, fosfora (na Ailab aparatu) i PTH (na Centaur aparatu) u krvi.

Rezultati i diskusija

Redni broj Inicijali Pol

Kalcijum (mmol/l)

Fosfor (mmol/l)

PTH (pg/ml)

1. V.V. Z 2,73 0,83 180,8

2. G.O. Z 2,74 0,92 101,0

3. M.V. Z 2,84 1,10 157,0

4. J.D. Z 2,91 0,69 123,0

5. D. Z. Z 2,85 0,80 215,0

6. V.S. Z 2,88 0,84 204,0

7. P.M. Z 2,88 0,66 146,0

8. C.Z. Z 3,10 0,77 116,0

9. A.R. Z 2,59 1,04 140,0

10. T.M. Z 2,63 0,65 150,0

11. M.S. Z 2,64 1,14 133,0

12. S.D. Z 2,78 0,69 210,0

13. C.Z. Z 2,80 0,92 121,0

14. B.D. M 2,97 0,98 190,0

15. M.A. Z 2,80 0,67 197,5

19UDRUENOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE...

16. J.A. M 2,78 0,95 342,0

17. T.R. Z 2,72 0,90 350,0

18. M.M. Z 3,10 0,60 310,0

19. L.D. Z 2,99 0,69 200,0

20. C.Z. Z 2,75 1,01 85,0

21. J.K. Z 2,80 1,13 210,0

22. T.S. Z 2,29 1,10 129,0

23. P.B. Z 2,70 1,20 115,0

24. S.M. Z 2,58 0,84 130,0

25. J.V. Z 2,70 0,92 168,0

26. A.Z. Z 2,78 0,86 166,0

27. I.V. Z 3,16 0,85 314,0

28. S.N. Z 2,87 0,69 267,0

29. H.S. Z 2,70 0,80 302,0

30. M.G. Z 2,38 0,88 95,2

31. L.D. Z 2,99 0,69 300,0

32. J.R. Z 2,87 0,70 309,0

33. K.K. Z 2,78 0,92 140,0

U naem radu prikazana su 33 pacijenta kojima smo u naoj ustanovi dijagno-stikovali primarni hiperparatireoidizam. Od ukupno 33 pacijenta, 31 su bile osobe enskog pola, to je 93,94%, dok su bila samo 2 mukarca, to je 6,06% uzorka.

Prose na vrednost kalcijuma u naoj grupi bila je 2,79 mmo/l. Najvia vrednost kalcijuma izmerena u naoj grupi bila je 3,16 mmo/l. Normalna vrednost kalcijuma u krvi u naoj laboratoriji od 2,15 do 2,50 mmo/l.

U naem radu prose na vrednost fosfora bila je 0,86 mmo/l. Najnia vrednost fosfora u naoj grupi bila je 0,60 mmo/l. Normalne vrednosti fosfora u naoj labora-toriji je 0,70 do 1,45 mmo/l.

Normalna vrednost PTH u naoj laboratoriji je 15 do 65 ng/ml, dok je prose na vrednost ovog hormona u naoj izabranoj grupi bila 187,16 ng/ml. Prose na vrednost PTH u naoj izabranoj grupi bila je skoro tri puta ve a od gornje granice normalnih vrednosti ovog hormona. Najvia vrednost PTH u naoj izabranoj grupi bila je 350 ng/ml, a najnia 85,0 ng/ml.

Na prvom pregledu svim naim pacijentima uradili smo ultrazvu ni pregled vrata, pri emu smo u 16 (51,51%) pacijenata sa velikom verovatno om mogli zaklju iti da se

20 MEDICINSKI GLASNIK / str. 17-23

radi o uve anim paratitastim lezdama.Od 16 pacijanata, kod 11 (33,33%) scintigra ja paratitastih lezda se u potpunosti poklapala sa ultrazvu nim nalazom vrata.

Svim naim pacijentima uradili smo EHO pregled bubrega, sa osvrtom na po-stojanje mikrolitijaze ili kalkuloze jednog ili oba bubrega.

Ultrasonografskim pregledom bubrega utvrdili smo da najve i broj naih pa-cijenata ima bilateralnu mikrolitijazu, 13, odnosno 40%. Kod 6 naih pacijenata nali smo obostranu kalkulozu bubrega, to je 18% uzorka. Samo 3 pacijenta iz nae grupe imala su kalkulozu levog bubrega, to je 9%, a kod jednog pacijenta utvrdili smo mikrolitijazu levog bubrega, to je 3% grupe. Negativan nalaz ultrasonogra je bubrega, u smislu da nema ni kalkuloze ni mikrolitijaze bubrega, nali smo kod 10 pacijenata, to je 30% naeg uzorka. (Gra k br.1)

Svim pacijentima iz nae grupe izmerili smo kotanu gustinu na naem Hologic explorer osteodenzitometru. Pregledom kotane gustine doli smo do podatka da su svi pacijenti iz nae grupe imali smanjenu kotanu gustinu, ili u smislu osteopenije ili osteoporoze. Od 33 naa pacijenta, 17 je imalo osteopeniju, to je 52% uzorka, dok je 16 imalo osteoporozu, odnosno 48%. (Gra k br. 2)

21UDRUENOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE...

Ura en je i scintigram paratitastih lezda svim pacijentima nae grupe. Kod 4 pacijenta utvrdili smo hiperaktivne dve paratitaste lezde, dok je kod ostalih bila hiperaktivna jedna paratitasta lezda. Donja leva paratitasta lezda pokazala se kao hiperaktivna u 12, a donja desna u 9 pacijenata. Iz grupe gornjih paratitastih lezda, leva je bila hiperaktivna kod 3 pacijenta, a desna kod 6.

Negativan scintigrafski nalaz imali smo u 8 pacijenata. (Gra k br. 3)

Scintigrafija paratitastih lezda

76%

24%

Pozitivan nalaz Negativan nalaz

22 MEDICINSKI GLASNIK / str. 17-23

Poreme aj gra e titaste lezde imali su svi pacijenti iz nae grupe. Od 33 pacijenta nae grupe, 20 je imalo difuznu strumu, to je 61% uzorka, 5 je imalo poli-nodoznu strumu, to je 15%, a 4 pacijenta su imala mikronodoznu strumu, odnosno 12% uzorka. Ukupno 4 pacijenta, po 2, to je 12% grupe, imala su nodozne promene u levom ili desnom lobusu titaste zlezde. (Gra k br. 4)

Eho pregled titaste lezde

61%15%

12%

6%6%

Struma diffusa Struma polynodosaStruma mycronodosa Struma nodosa l.dex.Struma nodosa l.sin.

Od 33 pacijenta sa primarnim hiperparatireoidizmom, 27 (82%) nije imalo pore-me aj funkcije titaste lezde, odnosno bili su eutireoidni. Ostalih 6 pacijenata, (18%), iz naeg rada imalo je smanjenu funkciju titaste lezde i svi su bili na terapiji levotirok-sinom, u trenutku dijagnostikovanja primarnog hiperparatireoidizma. (Gra k br. 5)

Hormonski status titaste lezde

82%

18%

Euthyreosis Hypothyreosis

23UDRUENOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE...

Zaklju ak

Iz naeg rada se vidi da od primarnog hiperparatireoidizma obolevaju prevashod-no osobe enskog pola, to se u potpunosti uklapa u dosad dostupne epidemioloke podatke.

Nai podaci su pokazali da je primarni hiperparatireoidizam povezan sa poreme-ajem gra e, ali ne i sa poreme ajem funkcije titaste lezde. Svi pacijenti kojima smo

dijagnostikovali primarni hiperparatireoidizam imali su neku vrstu poreme aja gra e titaste lezde, dok je samo 6 pacijenata imalo poreme aj funkcije titaste lezde i to u smislu hipotireoidizma. Svih 6 pacijenata iz naeg rada sa poreme ajem funkcije titaste zlezde bile su osobe enskog pola.

Zbog najve eg broja asimptomatskih oblika primarnog hiperparatireoidizma sa-vetuje se detaljno uzimanje anamnesti kih podataka, poseban osvrt na osobe enskog pola, i kod svih poreme aja gra e titaste lezde, dijagnostikovanih putem ultrazvuka, kontrolisati i funkciju paratitastih lezda.

Literatura

1. Harison. Interna medicina, 2004.2. B. Jakovljevi . Primarni hiperparatireoidizam prikaz slu aja bolesnice sa uznapredo-

valom bole u, Acta Medica Medianae 2009.3. Catherinne Cormier et al. Primary hyperparathyreodismus and osteoporosis in 2004. 4. Fraser W. Hyperparathyreodismus, Lancet 2009.

Sneana Marinkovi , Nenad Laketi 1

THE ASSOCIATION OF PRIMARY HYPERPARATHYROIDISM WITH DISORDERS OF THE THYROID GLAND AND CARPENTRY OUR EXPERIENCE

Introduction

Primary hyperparathyroidism is a generalized disorder of metabolism of cal-cium, phosphate and bone caused by an increased secretion of PTH. (Harrison, In-ternal Medicine, 2004). It occurs as a result of adenoma, hyperplasia or parathyroid carcinoma. Adenoma of one or more of the parathyroid gland is considered the most common cause of this disease. . The most frequent localization of adenomas is lower parathyroid adenoma in zlezdama.I And in parathyroid hyperplasia is dominated by the main cell. (Harrison, Internal Medicine, 2004). The disease has the highest inci-dence between the third and fth decade of life. (Harrison, Internal Medicine, 2004). Half or even more patients with primary hiperpartaireoidizmom are asymptomatic. Asymptomatic hyperparathyroidism is de ned as documented hyperparathyroidism without signs or simotoma that characterizes this disease. (Harrison, Internal Medicine, 2004). Primary hyperparathyroidism is the third most common endocrine diseases with the highest incidence among women in the postmenopausal period. (Fraser W. Hyperparathyreodismus, Lancet 2009).

The leading character is hypercalcemia that occurs due to increased bone resorpti-on, decreased urinary elimination of calcium and increased absorption in the intestine. In these patients, there is also calciuria, with an increased tendency to urolithiasis, then polyuria due to osmotic diuresis which leads to dehydration and loss of weight. (Reabsorption phosphate in the kidneys is reduced, which leads to hypophosphatemia and hiperfosfaturiji. The clinical picture depends on the value of parathyroid hormone and the degree of hypercalcemia. (Catherine Cormier, et al. Primary hyperparathyre-oidismus and osteoporosis in 2004).

Diagnosis of the disease is made based on elevated levels of PTH, elevated calcium levels and reduced levels of phosphate in the blood, ultarzvucnog inspection doors and parathyroid scintigraphy.

1 Special hospital for thyroid gland and metabolism diseases, Zlatibor

25THE ASSOCIATION OF PRIMARY HYPERPARATHYROIDISM WITH DISORDERS...

A disorder of the thyroid gland material manifetsuje as diffuse and nodular goiter, while disorders of the glands stiaste re ected in terms of an increased and reduced function or hyper and hypothyroidism. (Harrison, Internal Medicine 2004).

Show connections with primary hyperparathyroidism disorder functions and structure of the thyroid gland.

Material and methods

The investigation included 33 patients diagnosed with primary hyperparathyro-idism in a special hospital Cigota on Zlatibor, in the period from 1 January to 31 December 2014 year. For all patients, we performed ultrasound examination of the neck and kidney ultrasound equipment at General Electric Logiq 3, Dexa examination, the Hologic Explorer osteodensimeter, parathyroid scintigraphy (MIBI, technetium 99 M), the Siemens Orbiter Gamma camera, hormonal status stiaste glands, chemi-luminescence method the DPC apparatus, as well as levels of calcium, phosphorus (the ailable apparatus) and PTH (the Centaur apparatus) in the blood.

Results and discussion

Number Initials Gender Calcium(mmol/l)Phosphorus (mmol/l)

PTH (pg/ml)

1. V.V. Z 2,73 0,83 180,8

2. G.O. Z 2,74 0,92 101,0

3. M.V. Z 2,84 1,10 157,0

4. J.D. Z 2,91 0,69 123,0

5. D. Z. Z 2,85 0,80 215,0

6. V.S. Z 2,88 0,84 204,0

7. P.M. Z 2,88 0,66 146,0

8. C.Z. Z 3,10 0,77 116,0

9. A.R. Z 2,59 1,04 140,0

10. T.M. Z 2,63 0,65 150,0

11. M.S. Z 2,64 1,14 133,0

12. S.D. Z 2,78 0,69 210,0

13. C.Z. Z 2,80 0,92 121,0

14. B.D. M 2,97 0,98 190,0

26 MEDICINSKI GLASNIK / str. 24-30

15. M.A. Z 2,80 0,67 197,5

16. J.A. M 2,78 0,95 342,0

17. T.R. Z 2,72 0,90 350,0

18. M.M. Z 3,10 0,60 310,0

19. L.D. Z 2,99 0,69 200,0

20. C.Z. Z 2,75 1,01 85,0

21. J.K. Z 2,80 1,13 210,0

22. T.S. Z 2,29 1,10 129,0

23. P.B. Z 2,70 1,20 115,0

24. S.M. Z 2,58 0,84 130,0

25. J.V. Z 2,70 0,92 168,0

26. A.Z. Z 2,78 0,86 166,0

27. I.V. Z 3,16 0,85 314,0

28. S.N. Z 2,87 0,69 267,0

29. H.S. Z 2,70 0,80 302,0

30. M.G. Z 2,38 0,88 95,2

31. L.D. Z 2,99 0,69 300,0

32. J.R. Z 2,87 0,70 309,0

33. K.K. Z 2,78 0,92 140,0

In our study we showed 33 patients to thom we diagnosed primary hyperpa-rathyroidism in our institution. Of the total 33 patients, 31 were females, which is 93.94%, while there were only two men, which is 6.06% of the sample.

The average value of calcium in our group was 2.79 mmol / L. The highest amount of calcium was measured in our group was 3.16 mmol / L. The normal value of calcium in the blood in our laboratory from 2.15 to 2.50 mmol / L.

In our work, the average value of phosphorus was 0.86 mmol / L. The lowest value of phosphorus in our group was 0.60 mmol / L. The normal default value, of phosphorus in our laboratories is 0.70 to 1,45mmo / l.

Normally, PTH in our laboratory is 15 to 65 ng / ml, while the average value of this hormone in our selected group was 187.16 ng / ml. The average value of PTH in our selected group was almost three times higher than the upper limit of normal values of this hormone. The highest value of PTH in our selected group was 350 ng / ml, and the lowest 85.0 ng / ml.

27THE ASSOCIATION OF PRIMARY HYPERPARATHYROIDISM WITH DISORDERS...

On their rst visit to all our patients, we have done an ultrasound examination of the neck, where we are in 16 (51.51%), patients with a high probability could conclude that it was an enlarged parathyroid zlezdama.Od patients` 16, 11 (33.33%) scintigraphy parastitsatih gland completely coincided with ultrasound ndings neck.

All our patients we did ECHO examination of the kidneys with regard to the existence of microlithiasis or calculi of one or both kidneys.

Ultrasonography kidneys we found that the majority of our patients have bilateral microlithiasis, 13 or 40%. In 6 of our patients we found mutual calculosis kidneys, which is 18% of the sample. Only 3 patients from our group had calculosis left kid-ney, which is 9%, and in one patient we found microlithiasis left kidney, which is 3% of the group. Negative ndings renal ultrasonography, in the sense that there is not even microlithiasis renal calculi, were found in 10 patients, which is 30% of our sample. Chart No.1

28 MEDICINSKI GLASNIK / str. 24-30

All patients from our group, we measured bone density in our Hologic Explorer osteodensimeter. By examining the bone density we get to the data, that all patients in our group had reduced bone density, or in terms of osteopenia or osteoporosis. Of our 33 patients, 17 had osteopenia, which is 52% of the sample, while 16 have osteoporosis, or 48%. Chart No.2

We performed and parathyroid scintigraphy all patients of our group. In 4 patients we identi ed two hyperactive parathyroid gland, while the other was a hyperactive parathyroid gland. Lower left parathyroid gland proved to be hyperactive in 12, and the lower right to the upper 9 pacijenata.Iz groups parathyroid glands, the left was hyperactive in 3 patients, and right in 6.

Negative scintigramski nding we had in 8 patients. Chart 3

29THE ASSOCIATION OF PRIMARY HYPERPARATHYROIDISM WITH DISORDERS...

A disorder of the thyroid gland material were all patients from our group. Of the 33 patients of our group, 20 patients had diffuse goiter, which is 61% of the sample, 5 had a nodular goiter, which is 15%, and 4 patients had mikronodoznu goiter, or 12% of the sample. A total of 4 patients, 2, which is 12% of the group had a nodular lesion in the left or right lobe stiaste glands. Chart No.4

Of the 33 patients with primary hyperparathyroidism, 27 (82%) had disorders of thyroid function, or were euthyroid. The remaining 6 patients (18%), from our work had reduced function of the thyroid gland and all were treated with levothyroxine at the time of diagnosis of primary hyperparathyroidism. Chart No.5

30 MEDICINSKI GLASNIK / str. 24-30

Conclusion

From our work shows that of primary hyperparathyroidism affects primarily females, which completely ts to the available epidemiological data.

Our data showed that the primary hyperparathyroidism associated with distur-bance of composition, but not with disorders of thyroid function. All patients who were diagnosed primary hyperparathyroidism had some kind of material thyroid disorders, while only 6 patients had disorders of thyroid function and in the sense of hypothyroidism. All 6 patients from our work with disorders of thyroid function were females.

Because the greatest number asmiptomatskih primary forms hiperparatireoidz-ma advises a detailed medical history is taken, a special review of the females, and in all material stiaste gland disorder, diagnosed by ultrasound control and nkciju parathyroid.

Literature

1. Harison, Internal Medicine2. B.Jakovljevic, primary hyperparathyroidism -show case of a patient with advanced

disease, Acta Medica Medianae, 2009.3. Catherinne Cormier et al Primary hyperparathyreodismus and osteoporosis in 2004th4. W. Fraser Hyperparathyreodismus, Lancet, 2009.