Endocrine Abstracts

An 80-year old female was admitted to Ipswich Hospital with anorexia, constipation, thirst and fatigue. Her examination was unremarkable apart from 2 cm splenomegaly. Investigations revealed renal impairment (creatinine 293 umol/l), normal electrolytes along with hypercalcaemia (corrected Ca 3.54 mmol/l), normal PO₄, normal CXR, PTH of 3.3 pmol/l (NR -normal range- 0.95–5.7 pmol/l) and protein electrophoresis was normal. Abdominal USS confirmed splenomegaly. After aggressive re-hydration, she received 60 mg of pamidronate and her Ca²⁺ fell to 2.66 at the time of discharge. Two weeks later her symptoms had returned and her ACE returned at 176 Unit/l (NR 8–55), hypercalcaemia was again noted and urinary calcium was (8.14 mmol/day (NR<6). CT thorax and abdomen revealed only significant splenomegaly. One week later her Ca²⁺ had risen to 3.14 mmol/l and she was re-admitted. Repeat ACE was 207 U/l. US guided splenic biopsy confirmed the presence of granulomata and a diagnosis of sarcoidosis was made. Prednisolone (40 mg/d) commenced after re-hydration and she remained eucalcaemic. Two months later the patient unilaterally withdrew prednisolone therapy yet despite this she remains eucalcaemic. This is likely to reflect vitamin D deficiency (8.4, replete >30 Mcg/l) as serum ACE is consistent with active sarcoid (173 U/l). In time, it is anticipated with raised Vitamin D substrate through the summer that she will become hypercalcaemic whereupon alternative options will be required (ketoconazole, chloroquine or splenectomy).

We have identified 2 case further reports of isolated splenic sarcoidsis causing hypercalcaemia. In both, splenectomy resulted in the restoration of normal ACE and Calcium levels.

In conclusion, hyercalcaemia is most commonly associated with hyperparathyroid and malignancy. When splenomegaly is present the possibility of haematological malignancies must be entertained but alternative causes such as splenic sarcoidosis should be considered when low/normal PTH, and normal PO₄ levels are observed.