Endocrine Abstracts

Hypercalcemia is commonly caused by primary hyperparathyroidism. Other causes of hypercalcaemia can be seen in the clinical setting, and it is important to consider these alternative diagnoses as the management differs dramatically from the management of primary hyperparathyroidism. We present a series of four patients presenting with four different granulomatous conditions causing hypercalcaemia. These were secondary to Tuberculosis, Sarcoidosis, Wegener’s granulomatosis and Silicosis. All cases were referred to our endocrine department with unexplained hypercalcaemia. In the cases of sarcoidosis and silicon granulomata, hypercalcaemia was part of the initial presentation, whilst in the cases of tuberculous and Wegener’s granulomatosis, the associated hypercalcaemia was discovered after the primary diagnosis was established. Parathyroid hormone (PTH)was low or suppressed in all the cases while vitamin D levels (25 OHD) were low only in case of tuberculosis. We describe the presenting features, imaging and biochemistry associated with these four different granulomatous conditions. In all cases, normocalcaemia as well as a clinical improvement was achieved with treatment with prednisolone. Hypercalcaemia has been reported in a variety of granulomatous conditions. It is believed that activated mononuclear cells in the lung and/or lymph nodes produce activated Vitamin D independent of PTH and lead to hypercalcaemia. Treatment is usually with a course of prednisolone which is thought to impair intestinal absorption of calcium. Ketoconazole ahs also been used in patients unable to tolerate steroids. Granulomatous hypercalcaemia can pose a diagnostic challenge to physicians if this is the first presentation of the disease. A low PTH and a normal/low vitamin D in the setting of hypercalcaemia should raise concern regarding an unusual cause for hypercalcaemia. 1,25-dihydroxyvitamin D assessment is often unhelpful in the diagnosis as the reliability of the 1, 25 di-hydroxy cholecalciferol assay is often poor.

Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.

Case series of Granulomatous hypercalcaemia