uvod cilj rada materijal i metode rezultati...

Snežana Marinkovi , Nenad Laketi 1

POVEZANOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE I GRA E ŠTITASTE ŽLEZDE – NAŠA ISKUSTVA

Uvod

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

Cilj rada

Pokazati povezanost primarnog hiperparatireoidizma sa poreme ajem funkcije i gra e štitaste žlezde.

Materijal i metode

Istraživanjem 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 ženskog pola, što je 93,94%, dok su bila samo 2 muškarca, što je 6,06% uzorka.

Ultrasonografskim pregledom bubrega utvrdili smo da 40% našeg 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 naše grupe, što je 30% uzorka.

1 Specijalna bolnica za bolesti štitaste žlezde i bolesti metabolizna, Zlatibor

16 MEDICINSKI GLASNIK / str. 15-16

Pregledom koštane gustine došli smo do podatka da je 17 pacijenata naše grupe (52%) imalo osteopeniju, a 16 (48%) osteoporozu.

Negativan scintigrafski nalaz paraštitastih žlezda (MIBI) imalo je 8 pacijena-ta.

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

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

Zaklju ak

Našim radom pokazali smo da je primarni hiperparatireoidizam povezan sa poreme ajem gra e, ali ne i sa poreme ajem funkcije štitaste žlezde.

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

Snežana Marinkovi , Nenad Laketi

POVEZANOST PRIMARNOG HIPERPARATIREOIDIZMA SA POREME AJEM FUNKCIJE I GRA E ŠTITASTE ŽLEZDE – NAŠA ISKUSTVA

Uvod

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

tre e i pete decenije života (Harison, Interna medicina, 2004). Polovina ili ak i više pacijenata sa primarnim hiperparatireoidizmom su asimptomatski. Asimpto-matski hiperparatireoidizam de nisan je kao dokumentovan hiperparatireoidizam bez znakova ili simptoma koji karakterišu ovu bolest (Harison, Interna medicina, 2004). Primarni hiperparatireoidizam je tre e po u estalosti endokrinološko obo-ljenje sa najve om incidencom kod žena 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, što vodi dehidraciji i smanjenju telesne težine. Reapsorpcija fosfata u bubrezima je smanjena, što 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 povišenog nivoa PTH, povišenog nivoa kalcijuma i sniženog nivoa fosfata u krvi, ultrazvu nog pregleda vrata i scin-tigra je paraštitastih žlezda.

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


Cilj rada

Pokazati povezanost primarnog hiperparatireoidizma sa poreme ajem funkcije i gra e štitaste žlezde.

Materijal i metode

Istraživanjem 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 paraštitastih zlezda (MIBI, 99 M Tehnecium), na Simens Orbiter Gama kameri, hormonski status štitaste žlezde, 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

19UDRUŽENOST 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 našem radu prikazana su 33 pacijenta kojima smo u našoj ustanovi dijagno-stikovali primarni hiperparatireoidizam. Od ukupno 33 pacijenta, 31 su bile osobe ženskog pola, što je 93,94%, dok su bila samo 2 muškarca, što je 6,06% uzorka.

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

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

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

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


radi o uve anim paraštitastim žlezdama.Od 16 pacijanata, kod 11 (33,33%) scintigra ja paraštitastih žlezda se u potpunosti poklapala sa ultrazvu nim nalazom vrata.

Svim našim 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 naših pa-cijenata ima bilateralnu mikrolitijazu, 13, odnosno 40%. Kod 6 naših pacijenata našli smo obostranu kalkulozu bubrega, što je 18% uzorka. Samo 3 pacijenta iz naše grupe imala su kalkulozu levog bubrega, što je 9%, a kod jednog pacijenta utvrdili smo mikrolitijazu levog bubrega, što je 3% grupe. Negativan nalaz ultrasonogra je bubrega, u smislu da nema ni kalkuloze ni mikrolitijaze bubrega, našli smo kod 10 pacijenata, što je 30% našeg uzorka. (Gra k br.1)

Svim pacijentima iz naše grupe izmerili smo koštanu gustinu na našem Hologic explorer osteodenzitometru. Pregledom koštane gustine došli smo do podatka da su svi pacijenti iz naše grupe imali smanjenu koštanu gustinu, ili u smislu osteopenije ili osteoporoze. Od 33 naša pacijenta, 17 je imalo osteopeniju, što je 52% uzorka, dok je 16 imalo osteoporozu, odnosno 48%. (Gra k br. 2)


Ura en je i scintigram paraštitastih žlezda svim pacijentima naše grupe. Kod 4 pacijenta utvrdili smo hiperaktivne dve paraštitaste žlezde, dok je kod ostalih bila hiperaktivna jedna paraštitasta žlezda. Donja leva paraštitasta žlezda pokazala se kao hiperaktivna u 12, a donja desna u 9 pacijenata. Iz grupe gornjih paraštitastih žlezda, leva je bila hiperaktivna kod 3 pacijenta, a desna kod 6.

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

Scintigrafija paraštitastih žlezda

76%

24%

Pozitivan nalaz Negativan nalaz


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

Eho pregled štitaste žlezde

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 štitaste žlezde, odnosno bili su eutireoidni. Ostalih 6 pacijenata, (18%), iz našeg rada imalo je smanjenu funkciju štitaste žlezde i svi su bili na terapiji levotirok-sinom, u trenutku dijagnostikovanja primarnog hiperparatireoidizma. (Gra k br. 5)

Hormonski status štitaste žlezde

82%

18%

Euthyreosis Hypothyreosis


Zaklju ak

Iz našeg rada se vidi da od primarnog hiperparatireoidizma obolevaju prevashod-no osobe ženskog pola, što se u potpunosti uklapa u dosad dostupne epidemiološke podatke.

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

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

Zbog najve eg broja asimptomatskih oblika primarnog hiperparatireoidizma sa-vetuje se detaljno uzimanje anamnesti kih podataka, poseban osvrt na osobe ženskog pola, i kod svih poreme aja gra e štitaste žlezde, dijagnostikovanih putem ultrazvuka, kontrolisati i funkciju paraštitastih žlezda.

Literatura

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

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

Snežana 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


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.


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


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


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


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.

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