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A 67 year old lady is seen in ambulatory care. She had blood tests done by her GP as she described some tiredness. Her weight is stable. She has no bowel or bladder or other symptoms. She has no bone pain. Breast screening has been negative. She was found to have calcium of 3.1 mmol/L. She is otherwise well. She has noticed passing more urine and drinking more recently. Clinically she is euvolemic. She is a non-smoker and never smoked. She rarely drinks alcohol. Her past history is only hypertension diagnosed when she was 62. She takes Bendroflumethiazide. Her BP today is 123/78 mmHg. Her blood results are shown below.
137 - 144 mmol/L
3.5 - 4.9 mmol/L
95 - 107 mmol/L
20 - 28 mmol/L
12 - 16 mmol/L
2.5 - 7.5 mmol/L
60 - 110 micromol/L
Serum corrected Calcium
2.2 - 2.6 mmol/L
0.8 - 1.4 mmol/L
Serum Total protein
61 - 76 g/L
1. What causes of Hypercalcaemia do you know
Lung cancer and PTH related peptide release
Medicatons e.g. Vitamin D and Calcium, Thiazides
The majority are either cancer or primary hyperparathyroidism.
2. What tests would you do and why
Chest X Ray to look for cancer. Look for other clues towards malignancy. Such as evidence of smoking, weight loss and signs of malignancy e.g. clubbing. Hypercalcaemia is associated with the release of PTH related peptide by squamous cell lung cancer.
PTH level is key to diagnosing Primary hyperparathyroidism
Myeloma screen would be warranted if initial tests are unhelpful if ESR is elevated usually above 60 mm/hr or there is bone pain, lytic lesions or nephropathy
Sarcoid: ACE levels may be considered. Clues for sarcoid would a skin rash or bihilar lymphadenopathy seen on CXR
What would you do next
Initial management is rehydration. The calcium level is now 2.8 mmol/L and is generally asymptomatic. I would advise her to ensure she is well hydrated and send her home to await the results through ambulatory care. I would stop any calcium supplements or any drugs that retain calcium. I would bring back in a few days and if calcium is elevated I would give IV Pamidronate or Zoledronate
Her PTH result comes back and is normal. The other tests are also normal. What is the likely diagnosis
An elevated Calcium should suppress PTH levels to almost be undetectable. Sometimes the PTH level is very high but even a normal or high normal PTH is abnormal in the context of hypercalcaemia and the diagnosis is likely to be Primary hyperparathyroidism.
What should be the next step
She should be referred to endocrinology who can assess and refer to surgeons if they feel that consideration for parathyroidectomy is appropriate.
What are complications of the operation
Hypocalcaemia usually transient
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