Endocrine Abstracts

We report a case of hyperparathyroid crisis presenting with bradycardia (junctional rhythm) in a 65 years old ex nurse with manifestations of hypercalcemia of more than 10 years duration. She presented with palpitation, feeling light headed and not being herself for a day. She found her pulse to be 30/min, which triggered her admission to the accident and emergency department. She was not in any medication to cause hypercalcemia. On examination, she was dry and her thyroid was not enlarged. She had a pulse of 30/min and a BP of 105/55. Her ECG showed junctional rhythm.

• Initial investigations revealed

• Normal U/Es, TSH 3.41 mU/l, albumin 41 g/l,

• Adjusted Ca 3.65 mmol/l, {normal calcium=2.2–2.55 mmol/l}

• Magnesium 0.88 mmol/l, {normal Mg 0.7–1.2 mmol/l}

• Phosphate 0.77 mmol/l, {normal phosphate 0.81–1.55 mmol/l}

• 1, 25 Dihydroxy Vit D 98 ng/l {normal 20–50}

• Parathyroid hormone 51 pmol/l, {normal PTH 1.1–7 pmol/l}

• Prolactin 199 mU/l, {normal prolactin 102–496 mU/l},

• Normal chest X-ray.

• ECG showed junctional rhythm.

Treatment: She was rehydrated with 0.9% normal saline. She was also given frusemide 40 mg daily. Intravenous pamidronate infusion of 60 mg was started on admission then repeated on day 1, day 9 and day 10 as calcium level remained persistently high and while she was waiting for parathyroidectomy.

As the calcium level fell, the ECG changed to sinus rhythm.

Discussion: The effects of hypercalcaemia on the heart and electrocardiogram are well known but arrhythmia is an uncommon manifestation. An acute elevation of calcium level may cause bradycardia and first degree block, but junctional rhythm has not been reported in conjunction with hyperparathyroid crisis. Hypercalcemic crisis is a life-threatening condition. Once diagnosed, appropriate and adequate treatment measures need to be reinstituted without delay including referral to a surgeon for parathyroidectomy.