Endocrine Abstracts

We describe the case of a 70-year-old lady presenting with marked, symptomatic hypercalcaemia.

Past medical history was of insulin-treated Type 2 Diabetes, macrovascular disease and chronic renal impairment.

On admission, corrected calcium was noted to be 3.53 mmol/l with a paired PTH within normal range (4.3 pmol/l, range 1.6–9.3). Further questioning revealed a history of weight loss but no other clinical features specifically suggestive of malignancy. There was no personal or family history of endocrinopathy, and the patient was not taking any relevant medication.

Aside from clinical evidence of dehydration, examination was unremarkable and in particular, there was no evidence of finger clubbing, lymphadenopathy, breast or abdominal masses.

Investigations conducted including liver function tests, tumour markers, myeloma screen and bone scan were normal. A serum ACE was found to be moderately elevated at 113 IU/l (10–70) in the absence of overt respiratory, cutaneous or musculoskeletal pathology.

Following hydration and intravenous bisphosphonate therapy, corrected calcium remained elevated.

Although PTH was not elevated or indeed at the upper end of normal, a lack of clear malignant aetiology prompted a request for an ultrasound scan of the parathyroids. This displayed a right parathyroid lesion which corresponded to an area of increased uptake on subsequent Sestamibi imaging. The patient was referred for surgery in view of symptomology and degree of hypercalcaemia.

Surprisingly, histology showed a parathyroid adenoma with granuloma suggestive of sarcoidosis, as well as an area of thyroid tissue with features of granulomatous thyroiditis, also favouring sarcoidosis. These findings correlated with the elevated ACE and a subsequent high-resolution CT chest which showed evidence of nodular interstitial disease predominantly in the mid and upper zones.

The final diagnosis was therefore unexpected – sarcoidosis with granulomatous infiltration of the parathyroid gland resulting in hypercalcaemia.