Endocrine Abstracts

A 37-year-old gentleman was admitted following a GP referral for asymptomatic hypercalcaemia. His adjusted calcium was raised at 3.27 mmol/l while phosphate level was normal. The only past medical history was borderline hypertension which was being monitored in primary care. His PTH level was suppressed at 0.43 pmol/l l (1.1–5.5) while 25(OH) Vitamin D was normal at 71.6 nmol/l (48–145). Twenty-four hours urinary metadrenalines were normal. His full blood counts were also normal. He was treated with i.v. fluids and i.v. Pamidronate and the hypercalcaemia responded well and his calcium levels have remained normal since then. The suppressed PTH level prompted us to look for other causes of hypercalcaemia. Familial hypocalciuric hypercalcaemia and multiple myeloma were excluded. His chest X-ray showed diffuse nodular opacities but no other specific abnormalities were present. His serum ACE level was 266 U/l (8–52) and 1,25(OH)₂ Vitamin D was increased at >250 pmol/l (20–120). A CT scan of neck, chest and abdomen was arranged which showed subcentimeter lymphnodes at the level of carotid bifurcation and paratracheal region. There were also numerous ill defined foci throughout the lungs. It also showed an enlarged spleen (15 cm) with numerous hypo-attenuated foci in its parenchyma.

In view of splenomegaly a bone marrow biopsy was arranged which showed a reactive bone marrow with non-caseating granulomata and other changes in keeping with sarcoidosis.

His calcium levels currently remain in normal range and he is awaiting review by chest physicians.

Discussion: The incidence of bone marrow involvement in sarcoidosis is about 10%. In patients with bone marrow involvement, there is usually higher incidence of extrapulmonary manifestations, leucopaenia/lymphopaenia and anaemia.

In patients with hypercalcaemia, a normal screen for usual causes should lead to investigations for unusual causes of hypercalcaemia.