Skeletal Manifestations of Primary Hyperparathyroidism: A Series of Four Cases

Abstract

Primary Hyperparathyroidism (PHPT) has undergone a marked epidemiological shift worldwide, with Western countries reporting predominantly asymptomatic, screening-detected disease, whereas India continues to see a substantial burden of symptomatic PHPT. This case series describes four patients presenting with advanced skeletal manifestations of PHPT, highlighting diagnostic challenges, biochemical severity, and surgical outcomes. All patients presented with severe skeletal disease, including pathological fractures, brown tumours, and marked osteoporosis. Mean serum calcium and PTH of the cases were 13.7±1.5 mg/dL (12.3-15.1mg/dl) and 1960±929 pg/mL (870-2956 pg/ml) respectively. Diagnostic delay averaged 11.8 months, as all patients initially underwent extensive orthopaedic or oncologic evaluation. All four underwent parathyroidectomy for solitary adenomas and achieved complete biochemical cure. Hungry Bone Syndrome (HBS) occurred in all cases, requiring intravenous calcium. At one year, all patients demonstrated substantial clinical improvement, normalization of calcium and PTH, marked reduction in alkaline phosphatase, and significant gains in bone mineral density. Despite global declines in symptomatic PHPT, advanced skeletal disease persists in India, often compounded by vitamin D deficiency and diagnostic delay. Parathyroidectomy remains highly effective, producing excellent biochemical cure and dramatic skeletal recovery even in severe disease. Early calcium and PTH testing in patients with lytic lesions or unexplained fractures is essential for timely diagnosis.