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Am J Surg. 2019 Oct 22. pii: S0002-9610(19)30939-0. doi: 10.1016/j.amjsurg.2019.10.032. [Epub ahead of print]

Comparative prospective study on the presentation of normocalcemic primary hyperparathyroidism. Is it more aggressive than the hypercalcemic form?

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Endocrine Surgery Unit, General Surgery Department, Hospital Ramón y Cajal, Madrid, Spain. Electronic address:
Endocrine Surgery Unit, General Surgery Department, Hospital Fundación Jiménez Díaz, Madrid, Spain.
Endocrine Surgery Unit, General Surgery Department, Hospital Ramón y Cajal, Madrid, Spain.



Some patients with primary hyperparathyroidism (PHPT) have an elevated PTH that does not always correlate with high blood calcium levels. We aimed to compare the clinical presentation between normocalcaemic and hypercalcaemic forms using ionized calcium levels as an inclusion criterion.


We included all patients referred for surgery for PHPT between January 2015 and December 2017. Patients were divided into 2 groups (hypercalcaemic (hPHTP)/normocalcaemic (nPHPT)).


104 patients were included.64% of the patients who were initially classified as normocalcaemic had high ionized calcium levels. There were no differences between groups except in terms of bone resorption parameters:patients with hypercalcaemia had higher osteocalcin (37.4vs23.5 ng/mL,P = .02), collagen amino-terminal propeptide (73.5vs49.2 ng/mL,P = .005), and beta-CTX levels (0.68vs0.38 ng/mL,P = .001). Bone involvement as measured by densitometry was similar.


When these patients' diagnosis and classification is accurate, their clinical presentation and symptoms are similar to those of the classical form. Since the only difference is in terms of bone resorption parameters, in most cases it seems to be an attenuated form or even similar to the classical presentation. The improvement in diagnostic sensitivity supports the use of ionized calcium levels in patients suspected to have nPHPT.


Clinical presentation; Ionized calcium levels; Normocalcaemic hyperparathyroidism

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