hiperparatiroidimso
TRANSCRIPT
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NOMBRE: MMF
EDAD: 67 AÑOS
PROCEDENCIA: FLORENCIA CAQUETA
OCUPACION: HOGAR
REMITIDA HOSPITAL “INMACULADA”
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ENFERMEDAD ACTUAL
“2 meses de evolución de dolor abdominal intermitente, agudiza la semanafinal de noviembre por lo que consulta a Florencia. / En TAC encuentran “masaen la cabeza del páncreas” de aspecto maligno, cambios por pancreatitisBaltazar D…. remiten para manejo de la obstrucción”
Rs/ Perdida de peso de 12 kg. Dolor abdominal recurrente (últimos 6 meses)
“CAMBIOS EN LA CONDICION COGNITIVA Y DEL COMPORTAMIENTO”
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ANTECEDENTES:
PAT: Hipertension arterial, poliartrosis, migraña
FARM: Aspirina, Captopril, Hidroclorotiazida, Omeprazol
FAM: No Referido
QUIRURGICOS: Niega
TOXICO ALERGICOS: No Conocidos
G7 / P7
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EXAMEN FISICO
Signos Vitales: FC: 87 FR: 20 TA: 148/93
Cabeza y cuello:Palidez, anicterica. No palpación de ganglios cervicales
Cardiopulmonar: Soplo sistólico grado II en foco aórtico, sin agregados pulmonares
Abdomen: Blando. Leve dolor con la palpación periumbilical, hernia umbilical reducible,
no masas.
Neurológico. Alerta desorientada en tiempo y espacio, resto de las funci0nes mentales
adecuadas, cambios por reacondicionamiento fisico
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LABORATORIOS DE INGRESO
AMILASA (SUERO) V - 279 CLORURO SUERO V- 111.5 CREATININA - 1.17 Directa: - .24 FOSFATASA ALCALINA - 192 GLICEMIA SUERO V - 81 HB.CORPUS.MED - 26.6 HEMATOCRITOS - 25.9 HEMOGLOBINA -8.05 Indirecta: - .12 LEUCOCITOS - 6.55 LINFOCITOS - 21.96 NEUTROFILOS - 55.85
NITROGENO UREICO - 13.7 PLAQUETAS: - 492 POTASIO SUERO V - 3.52 SODIO SUERO V - 140 TRANSAMINASA GOT V -18 TRANSAMINASA GPT - 17 Total: - .36 Ccr: 44
GA: Acidosis metabólicaCompensada
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REPORTE DE LA TOMOGRAFIA DE ABDOMEN:
“Engrosamiento de las paredes del colon , con moderada alteración de la grasa pericolonica, por probable compromiso por proceso inflamatorio (colitis) sin proceso obstructivo secundario. Múltiples lesiones líticas subcentimetricas en estructuras óseas de abdomen y la pelvis sospechosas de mieloma múltiple a correlacionar con datos clínicos. El páncreas es de aspecto normal sin dilatación del conducto pancreático. Se observa quiste simple en el proceso uncinado. No dilatación biliar”
Masa??
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DIAGNOSTICO DE MANEJO AL INGRESO
1. Síndrome constitucional a estudio
2. Antecedente de pancreatitis en resolución
3. Neoplasia de la cabeza del páncreas a descartar
4. Sd anémico de etiología determinar
5. Lesiones osteoliticas vertebrales y en pelvis sugestivas de mieloma multiple
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Valoración por hematología▪ Serie ósea, electrolitos. Determinara BMO*, estudios biológicos
Se recibe llamado de enfermería, paciente con agitación psicomotora, desorientación en tiempo, espacio y persona, signos vitales: TA:170/90, FC:70xm, :18xm, se formula haloperidol 5 gotas ahora, se continua vigilancia evolución clínica + dosis de Enalapril de 20 mg
Estudios de demencia reversible
Valoración por neurología
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Osteopenia moderada.La altura los cuerpos vertebrales amplitud de los espacios intervertebrales es normal.Formación discreta de osteofitos marginales anteriores en C4-C5 C5-C6 por fenómeno de espondilosis incipiente.
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RADIOGRAFÍA DE COLUMNA TORACOLUMBAR:
Se observa escoliosis lumbar de convexidad derecha, con importante componente rotacional.
Osteopenia difusa, con configuración bicóncava de cuerpos vertebrales, que sugiere fracturas por insuficiencia, en particular en los segmentos L3 L2-L1.
Restos de de material de contraste en el colon.
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RADIOGRAFÍA DE MUSLOS COMPARATIVOS.
No se observan alteraciones en la trabécula ósea, cortical no medular del fémur. La relación articular coxofemoral está preservada.
Calcificaciones inespecíficas localizadas hacia la región inguinal bilateral.
Se aprecia disminución de los espacios articulares femorotibial medial bilateralmente, con esclerosis de superficies articulares, irregularidad de la
superficie de la rótula, y calcificación en los meniscos articulares, por fenómenos de osteoartrosis importante.
CONCLUSIÓN:
No se identifican lesiones líticas óseas.
Importantes cambios de osteoartrosis bilateral de rodillas.
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RADIOGRAFÍA COMPARATIVA DE BRAZOS.En el húmero derecho se observan al menos tres lesiones ovaladas líticas localizadas en la diáfisis del tercio superior del mismo.Bilateralmente pero especialmente el lado derecho hay cambios de tipo degenerativo, con disminución del espacio articular acromiohumeralirregularidad de las cabezas humerales por artrosis en esta localización, con calcificaciones en los tejidos blandos adyacentes a la cabeza humeral.En el lado izquierdo erosión de el extremo distal de la clavícula.
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PARACLINICOS POR HEMATOLOGIA
ASPIRADO Y BIOSPIA DE MEDULA OSEA NEGATIVO PARA DISCRASIA DE CEL PLASMATICAS
B2 MICROGLOBULINA: NEGATIVO
ELECTROFORESIS DE PROTEINAS NEGATIVO PARA PICOS MONOCLONALES.
MARCADORES TUMORALES
CA 125, ACE, CA 19.9 ALFA FETOPROTEINA NEGATIVOS
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TOMOGRAFIA COMPUTARIZADA CEREBRAL SIMPLE
“Imágenes indicativas de pequeños infartos sub agudos o crónicos en territorio de arteria cerebral media izquierda”
PUNCION LUMBAR
“Negativa para infección u otras alteraciones que indiquen malignidad”
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GLUCOSA - 58
MAGNESIO SUERO V - .51
POTASIO SUERO V - 2.94
PROTEINAS TOTALES - 33.8
CALCIO TOTAL: 14. 83 CORREGIDO: 16 IONICO: 2.05
SS. PTH, BIOPSIA DE LAS LESIONES LITICAS OSEAS
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NEJM Volume 343 Number 25, 2000
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EF: AUMENTO DEL VOLUMEN TIROIDEO DERECHO
SS. ECOGRAFIA TIROIDEA
PTH: 677 CALCEMIA: 16
HIPERPARATIROIDMO PRIMARIO??
SS/ GAMMAGRAFIA DE PARATIROIDES Y TECNICAS DE MEDICINA NUCLEAR
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“Se observa captación en polo superior derecho yen menor proporción en el polo inferiorizquierdos, con "aclaramiento lento”, hallazgosque se deben correlacionar con gammagrafía detiroides”.
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MANEJO MEDICO DE LA HIPERCALCEMIA
1. Hidratación
2. Zolendronato
3. Calcitonina
4. Diálisis
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ZolCalcitDiálisisEsteroCx
Nivel superior normal de calcio
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RESOLUCION DEL MANEJO
1. Diagnostico de hipoparatiroidismo primario
2. Manejo de la hipercalcemia con diálisis ante dificultad con manejo medico general y valoración por cirugía de cabeza y cuello
3. Cirugía con paratiroidectomia
4. Manejo de complicaciones del postoperatorio
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Resección (Paratiroides Inferior Izquierda) (Reportado 8:40 am “Adenoma paratiroideo”)
Resección (Paratiroides Inferior Derecha) (Reportado 8:46 am “Adenoma Paratiroideo”)
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Evolución
Post operatorio sin complicación
Mejoría gradual de la condición cognitiva y funcional
No sintomas por hipocalcemia clínica. No necesidad de reposición parenteral
Alta Hospitalaria y manejo ambulatorio
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HISTORIA
Fuller y Albright (1930) “Cálculos, huesos y gemidos”
70´s se hace detección más frecuente
Hiperparatiroidismo sintomático es actualmente la excepción
Variedad de formas de presentación
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GLANDULA PARATIRORIDES
4 Glándulas
4 polos posteriores de la glándula tiroides
Ppal. producto PTH (84 aa)
Principal modulador de la homeóstasis del calcio
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Secreción inapropiada de PTH
Adenoma (75 – 80%)
Hiperplasia primaria (difusa o nodular) 10- 15%
Adenoma doble 4%
Carcinoma 5% - (1%)
Mayoría asintomáticos
Mayores de 50 años
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NEJM Volume 343 Number 25, 2000
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La mayoría se presentan con hipercalcemia
Mas común en postmenopausia
1% de la población adulta
2% en > de 55 años
2:1 M/H
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NEJM Volume 343 Number 25, 2000
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FACTORES DE RIESGO
Radiación previa del cuello
Uso prolongado de litio para trastornos afectivos
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CARACTERISTICAS ESPECIALES
Mayoría único
2 – 4 % múltiples
Localización no esperada
Enfermedad multiglandular (MEN 1 – MEN 2) (7 - 8 %)
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Sintomatico(Urolitiasis, dolores abdominales, síntomas neurológicos)
Vs
“Asintomatico”
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Mayo Clin Proc. • March 2007;82(3):351-355
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Hipercalcemia vs calcio normal alto
+
Elevación de la PTH (intacta)
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Osteitis fibrosa quística
Cráneo en sal y pimienta
Resorción de la clavícula distal
Tumor pardo
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Nefrolitiasis
Nefrocalcinosis
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Hipertensión arterial
Hipertrofia ventricular izquierda
Arritmias
Hipercontractilidad
Calcificación de estructuras endocardicas
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EVALUACION A TODOS LOS PACIENTES
Medición de la densidad mineral ósea (DEXA)
Recolección de orina de 24 horas (calcio y creatinina)
Vitamina D sérica, fosfatasa alcalina, fosfato, cloro, nitrogenados
Imagenologia
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www.aafp.org/afp
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RESECCION DE PARATIROIDES
Única alternativa curativa
Curación 95 % – 98%
Resección focal
Busca normalización de la PTH
Resección total del adenoma
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TheOncologist 2007;12:644–653
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1 – 2 %
Daño del nervio l. Recurrente
Persistencia
Permanente
Sangrado
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CAUSAS
Enfermedad multiglandular
Ectopia y supranumerario
Cáncer
Inexperiencia
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J Clin Endocrinol Metab, February 2009, 94(2):335–339
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J Clin Endocrinol Metab, February 2009, 94(2):335–339
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J Clin Endocrinol Metab, February 2009, 94(2):335–339
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Dieta y hábitos de vida
Bifosfonatos
Calcimimeticos
Estrógenos
Ablación percutánea con alcohol
Evitar medicaciones toxicas
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