Search 

Interpretation of Parathyroid Abnormalities

Vincent Ziglioli, DVM, Virginia-Maryland Regional College of Veterinary Medicine
David Grant, DVM, MS, DACVIM, Virginia-Maryland Regional College of Veterinary Medicine

DECEMBER 2015 | ENDOCRINOLOGY & METABOLIC DISEASES | WEB-EXCLUSIVE

Print/View PDF

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 e 4 parathyroid glands typically measure less than 2 to 3 mm on ultrasound1 and play a pivotal role in calcium homeostasis in both dogs and cats.
Parathyroid hormone (PTH) is synthesized, stored, and secreted by parathyroid chief cells in response to low serum ionized calcium (iCa)

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 concentration. A G-protein coupled calcium-sensing receptor is responsible for detecting low iCa concentrations, which ultimately result in PTH
secretion.2 PTH secretion causes increased calcium reabsorption in the distal renal tubules, increased production of calcitriol, increased intestinal
calcium absorption, and increased calcium resorption from bone.3 Other stimuli for PTH secretion include increased serum phosphorus and
decreased calcitriol concentrations. Inhibition of PTH secretion is primarily controlled by increased serum iCa concentrations, but increased
calcitriol and decreased magnesium concentrations can also contribute to the inhibition.3

Related Article: Anesthesia for Parathyroid Disease

Primary hyperparathyroidism (PHPT) is seen more commonly in dogs (than in cats), usually at 6 years of age or older, with a median age of 11 years
at diagnosis.4 ere is no gender predisposition, but there does seem to be a breed correlation, with the highest incidence of hyperparathyroidism in
the Keeshond.4,5 e most common clinical signs seen in dogs with hyperparathyroidism include polyuria and polydipsia (57%), lower urinary tract
signs (eg, pollakiuria, stranguria, hematuria; 50%), weakness (46%), decreased activity (43%), reduced appetite (37%), weight loss or muscle wasting
(18%), vomiting (13%), and trembling (10%), with close to 37% of dogs exhibiting no clinical signs.4

PHPT is less frequently diagnosed in cats as compared to dogs; in cats, the median age is 13 years, with no apparent gender predisposition.6 e
most common clinical signs include anorexia, lethargy, and vomiting, with polyuria and polydipsia, weight loss, and constipation less common.7 A
nodule in the neck is usually palpable in cats, whereas a palpable nodule is identi ed less frequently in dogs.8

Primary hypoparathyroidism, which is uncommon in both dogs and cats, is usually diagnosed as idiopathic (by exclusion) or occurs as a surgical
complication of thyroidectomy (accidental removal or injury).9 Clinical signs are attributable to hypocalcemia and include seizures, muscle tremors
or fasciculations, muscle cramping, sti gait, and behavioral changes (eg, restlessness, aggression, hypersensitivity to stimuli, disorientation).10 In a
majority (77%) of dogs, duration of clinical signs prior to diagnosis is often fewer than 14 days but can be as high as 173 days.11

Related Article: Primary Hyperparathyroidism

e standard diagnostic approach for parathyroid disorders generally consists of patient history, physical examination, complete blood count,
serum chemistry pro le, and urinalysis. In a large proportion of both canine and feline cases, incidental detection of decreased or increased serum

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 total calcium typically leads to initial clinical suspicion of hypo- or hyperparathyroidism.6,12 With a 73%13 and 60%14 agreement between serum total
calcium (tCa) and iCa concentrations in dogs and cats, respectively, tCa concentration is a poor predictor of iCa concentration. erefore, iCa
should be evaluated after initial total hypercalcemia is con rmed on a nonhemolyzed, nonlipemic sample6 or in situations in which parathyroid
disease is suspected based on appropriate history, signalment, and/or clinical signs.

In patients with PHPT, cervical ultrasonography performed by an experienced ultrasonographer is recommended and often helps establish a
diagnosis. Cervical ultrasonography can identify a parathyroid nodule, usually occurring as a solitary nodule in 90% of patients and averaging 4 to 6
mm in diameter in up to 100% of dogs with PHPT.4 Inappropriately normal to elevated PTH levels and undetectable parathyroid hormone-related
protein (PTHrP) levels can also aid in the diagnosis of hyperparathyroidism, especially in cases lacking an obvious detectable parathyroid nodule on
ultrasound. In patients with normal calcium homeostasis, PTH release should be inhibited by high circulating levels of iCa, resulting in low
circulating PTH concentrations. However, in patients with PHPT, the negative feedback inhibition is abolished because of the excess secretion of
PTH, commonly caused by a functional adenoma.

In patients with PHPT, PTH levels are inappropriately increased, either within or above the reference range, along with a nding of concurrent
hypercalcemia. It is important to have both PTH and iCa measurements performed on the same blood sample. However, results are often delayed
and treatment is usually based on ruling out other di erentials for hypercalcemia and ndings of a parathyroid nodule on cervical ultrasonography.
Scintigraphy is not commonly used to diagnose PHPT because of its low sensitivity and overall accuracy of 27%.15

De nitive diagnosis of primary hypoparathyroidism involves a PTH concentration within or below the reference interval, along with concurrent
hypocalcemia. Table 1 shows iCa, phosphorus, PTH, PTHrP, and vitamin D levels associated with various diseases commonly seen in dogs and cats
with hypo- or hypercalcemia.

Discussion on the treatment of parathyroid disorders is beyond the scope of this summary review but includes surgical removal or percutaneous
heat ablation in patients with PHPT and medical management with oral calcium and calcitriol supplementation, usually lifelong, in patients with
primary hypoparathyroidism. e overall prognosis for long-term survival in dogs and cats with parathyroid disease is usually good to excellent.6

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 Table 1. Laboratory Findings for Various Diseases Commonly Seen in Patients with Hypercalcemia and
Hypocalcemia 6,16-18

Primary hypoparathyroidism

Ionized Calcium ↓

Phosphorus ↑

Parathyroid Hormone N-↓

Parathyroid Hormone– Related Protein Absent

Vitamin D (25-hydroxyvitamin D) ↓

Chronic kidney disease

Ionized Calcium ↓-N-↑

Phosphorus N-↑

Parathyroid Hormone N-↑

Parathyroid Hormone– Related Protein Absent

Vitamin D (25-hydroxyvitamin D) ↓

Secondary nutritional hyperparathyroidism

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 Ionized Calcium N-↓

Phosphorus N-↑

Parathyroid Hormone ↑

Parathyroid Hormone– Related Protein Absent

Vitamin D (25-hydroxyvitamin D) ↓

Vitamin D toxicosis

Ionized Calcium ↑

Phosphorus N-↑

Parathyroid Hormone ↓

Parathyroid Hormone– Related Protein Absent

Vitamin D (25-hydroxyvitamin D) ↑

PHPT

Ionized Calcium ↑

Phosphorus N-↓

Parathyroid Hormone N-↑

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 Parathyroid Hormone– Related Protein Absent

Vitamin D (25-hydroxyvitamin D) N-↑

Idiopathic hypercalemia

Ionized Calcium ↑

Phosphorus N

Parathyroid Hormone ↓

Parathyroid Hormone– Related Protein Absent

Vitamin D (25-hydroxyvitamin D) ↓

Hypercalcemia of malignancy

Ionized Calcium ↑

Phosphorus N-↓

Parathyroid Hormone ↓

Parathyroid Hormone– Related Protein ↑

Vitamin D (25-hydroxyvitamin D) N-↑

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 ↓ = decrease, ↑ = increase, N = normal, PHPT = primary hyperparathyroidism

iCa =ionized calcium, PHPT = primary hyperparathyroidism, PTH = parathyroid hormone, PTHrP = parathyroid hormone-related protein, tCa = total
calcium

REFERENCES AND AUTHOR INFORMATION SHOW 

Material from Clinician’s Brief may not be reproduced, distributed, or used in whole or in part without prior permission of Educational Concepts, LLC. For questions or
inquiries please contact us.

PRACTICE TOOLS

Take the next step with career resources and job openings.

VISIT THE CAREER CENTER

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 TOPIC

Endocrinology & Metabolic Diseases

VIEW TOPIC

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 Clinician's Brief provides relevant diagnostic and treatment information for small animal
practitioners. It has been ranked the #1 most essential publication by small animal
veterinarians for 9 years.*

*2007-2017 PERQ and Essential Media Studies

It's Free & Simple Delivered to Your Inbox

 Subscribe  Newsletter
Join the Conversation Follow us @CliniciansBrief

 Facebook  Twitter

HOME LATEST ISSUE

ABOUT US EMPLOYMENT

SIGN IN GLOBAL EDITION

CONTACT US BRIEF MEDIA

CREATE ACCOUNT CAPSULES

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
 © 2018 Educational Concepts, L.L.C. dba Brief Media ™ All Rights Reserved. Privacy Policy (Updated 05/08/2018) Terms of Use (Updated 05/08/2018)

Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD