BACKGROUNDPrimary hyperparathyroidism (PHPT) has a variable clinical expression. Symptomatic PHPT is still the predominant form of the disease in many parts of the world, especially developing countries. Because the clinical profile of the disease has changed from that described in the past, we sought to improve our understanding of the disease in patients in north India.METHODSWe summarized the clinical presentation, biochemical and radiological features, and operative findings from the case records from the last 13 years of 52 patients at a tertiary care centre in north India who had documented PHPT.RESULTSThe male: female ratio was 1: 3.3 with ages ranging from 6 to 60 years (mean±SD, 36.38±12.73). Bone disease (46%), recurrent renal stones (21%) and body aches and pains (21%) were the most common modes of presentation. The lag time varied ranged from 1 month to 16 years. Common clinical manifestations included bone pain (67%), weakness/fatigue (56%), fracture of the long bones (48%), abdominal pain (39%), polyuria (37%) and psychiatric manifestations (23.1%). Hypertension was observed in 42% and a palpable nodule in the neck in 19%. Biochemical features included hypercalcemia (86.5%), hypophosphatemia (65.4%) and hyperphosphatasia (67.3%). Mean intact PTH (±SD) was 809.0±696.3 ng/L with levels significantly lower in patients who had only kidney stone disease as compared with those with bone disease (P=0.017). A single parathyroid adenoma was localized in 50 (98%) patients. Hungry bone disease was seen in 59% patients.CONCLUSIONPHPT in India continues to be a symptomatic disorder with skeletal and renal manifestations at a much younger age.

Only five cases of subarachnoid-pleural fistula in children have been reported previously. All had a history of trauma and associated neurologic deficit which gave clue to the diagnosis. The authors present a child who presented with a massive, rapidly filling, clear pleural effusion in whom there was no neurologic deficit. The history of an automobile accident in the past had almost been forgotten. A subarachnoid-pleural fistula was discovered on exploratory thoracotomy. The entity should be thought of, and actively investigated, in a child with a history of trauma and a pleural effusion of obscure etiology, even if there is no associated neurologic deficit.