ACTA ENDOCRINOLOGICA (BUC)

Aims: we wanted to check the importance of sunlight exposure and vitamin D supplementation in reverting secondary hyperparathyroidism at IIIrd age institutionalized patients.\r\nDesign: cross-sectional study of calcium and bone metabolism in a group of 123 institutionalized IIIrd age volunteers after winter period, followed by a prospective double blind placebo-controlled study of effects upon calcium and bone metabolism, serum 25OHD3, 1,25(OH)2D3 and PTH levels of daily sunlight exposure during the summer months, with or without vitamin D supplementation (2000 IU 25OH-D3 po, daily). The study was performed on volunteers from the Elderly Resting House of Copou,\r\nIasi, Romania. 25OH-D3 was measured by an inhouse RIA technique. 1,25(OH)2D3 was measured by HPLC, serum calcium by photocolorimetry, bone alkaline phosphatase by immunoenzymatic technique, whereas serum PTH and urinary deoxypyridinoline (DPD) were measured by IRMA. Data was compared using Student&#8217;s t test and correlation analysis (R2). Almost all volunteers (93.5%) had low 25OH-D3 values, but normal or even increased levels of the active hormone, 1,25(OH)2D3. High PTH was found in 41 cases (33.3%), of which three were primary hyperparathyroidism, whereas the others had low or low-normal calcium levels (secondary hyperparathyroidism). More than half of the cases had high DPD levels, suggesting high bone turnover. Bone turnover parameters were higher in females than in males (p<0.05). A positive correlation between PTH and urinary DPD was noticed (R2=0.351). We further supplemented the vitamin D intake in 42 volunteers with a daily dose of 2000 IU of 25-OHD3 for three months in the summer period, whereas other 42 volunteers received placebo (vitamin B). Normalization of 25-OHD3 levels was seen in both vitamin D and placebo-treated sun-exposed groups. A more significant increase in 25OHD3, and also of 1,25(OH)2D3 at the upper limit of normal was however observed in the vitamin D-treated group. Normalization of serum PTH, but not of turnover parameters was observed in both groups. Mild hypercalcemia and increase in serum creatinine were noticed in the vitamin D-treated group.\r\nConclusions: Secondary hyperparathyroidism might be of importance in high turnover bone loss at institutionalized IIIrd age patients. Women seem to be more at risk, possibly due to sex hormone depletion. PTH-induced 1&#945; hydroxylation in the elderly with undamaged kidney function partially compensates the paucity of vitamin D substrate, by normalizing active hormone levels. Mild sun exposure at institutionalized patients increases skin resources of vitamin D, normalizing 25OH-D3 levels and reverting secondary hyperparathyroidism. Oral vitamin D supplementation added to sunlight exposure should be done with caution, since it might be accompanied in certain patients by hypercalcemic or nephrotoxic effects at doses higher than 2000 IU/day.

We present the case of a 28 year old pregnant primiparous woman, suspected of primary hyperparathyroidism due to hypercalcemia discovered by routine calcium assessment at 30 weeks of gestation. Diagnosis was strongly suggested by elevated serum calcium (15.2 mg/dL, normal range: 8.4-10.3 mg/dL), low serum phosphorus (0.55 mg/dL, normal range: 2.5-5 mg/dL) and increased urinary hydroxyproline excretion (118 mg/24h, normal range: 10- 40 mg/24h), suggesting high bone turnover and confirmed by coexistence of high levels of parathyroid hormone (PTH, 145 pg/mL, normal range 10-65 pg/mL). Neck ultrasound identified a solid nodule of 33x58x20.5 mm situated behind the inferior pole of a normal thyroid left lobe, suggestive for a solid parathyroid tumour located within the left inferior parathyroid gland. Medical treatment with furosemide and hydration decreased serum calcium level but failed to normalize it. After a 3 day preparation for lung maturation with dexamethasone (16 mg per day), successful adenomectomy was performed under local anaesthesia, without major intraoperative or postoperative events. The few uterine contractions were easily managed with papaverine and progesterone. Calcium levels immediately returned to normal after surgery. Our patient delivered a healthy newborn at 40 weeks by caesarean section. A DXA BMD assay performed after one year showed significant bone loss of the mother at radius level (T score of - 2.6).

Despite an adequate medical treatment of Graves ophthalmopathy (GO), sometimes surgery is required to establish accurate eye movement and avoid severe complications. We present such a woman with Basedow's disease and evolutive exophthalmia despite adequate medical approach. At the admission (2005) she had clinical signs of thyrotoxicosis, TSH = 0.1 mUI/L, FT4 = 4.2 ng/dl and antithyroperoxidase antibodies = 342 UI/ml. Proptosis was 26 mm at the right eye and 25 mm at the left one, with intraocular tension 20 mmHg and NO SPECS score 4. Treatment with methimazole (30 mg/day), propranolol (30 mg/day), and corticotherapy (Metilprednisolone, 3x1g/day iv), improved the hyperthyroidism but not the ocular signs. The euthyroidism was maintained with 5 mg Methimazole daily. In February 2006 a new pulse therapy with Metilprednisolone (1g/day iv 3 days) was started, followed by Prednisone 30 mg /day, without significant improvement of the ocular signs. In June 2006, TSH receptor antibodies were high, TRAb=16.3 U/l, with euthyroid status but evolutive proptosis. The MRI showed an increase of the volume of all intraorbital muscles, a decrease of the optic nerve diameter. The patient had progressive GO with photophobia, palpebral edema, hyperlacrimation and conjunctivitis. The surgical treatment was decided when the proptosis was 25 mm and the intraocular tension was 19 mm Hg for both eyes. The patient was submitted to orbital content decompression through lipectomy and osteotomy of the orbital floor. The postoperative follow-up was uneventful. Two years postsurgery, exophthalmometry was 17 mm at right eye and 18 at the left eye, with an intraocular tension of 13 mm Hg. The MRI showed normal intraorbital muscles and ocular globe; the bicanthal lines were anterior to the posterior pole of the ocular globe. The patient had no limitation of the eyes movements, photophobia or conjunctivitis and a significant esthetic improvement.