Endocrine Abstracts

Hypercalcaemia is one of the common cases seen in Endocrine clinics. We report another challenging case of hypercalcaemia. A 43 old Asian man was referred by GP initially in 2011 with asymptomatic hypercalcaemia of 2.87 mmol/L. His past medical history included chronic plaque psoriasis with arthropathy, hypertension, stage 3 CKD, Fatty liver with mild fibrotic change secondary to methotrexate and learning difficulties. Hypercalcamia was thought to be contributed by Dovonex (Calcipotriene), Dovobet (Calcipotriol) and Bendroflumethiazide as calcium was nomal prior to starting Vitamin D analogues. These medications were changed and calcium levels subsequently settled to 2.62 mmol/L (PTH 1.4).

Calcium rose to 3.05 mmol/L in early 2013 and patient was symptomatic. Despite oral fluids at home, calcium further rose to 3.50 mmol/L with non suppressed PTH 3.1. 24 hour urinary Calcium 6.3 mmol. Ultrasound, SPECT MIBI and thyroid pertechnetate scan showed poorly tracer concentrated PTH adenoma. He had full neck exploration in April 2013, and 2 parathyroid glands (right inferior and left superior) were identified and removed. Biopsy revealed mild hyperplasia.

Postoperatively, calcium remained normal until February 2015 cca 2.67, proceeding to recurrent hypercalcaemia with 6 emergency admissions with vomiting, dehydration fro May 2015 to January 2016, requiring IV fluids and bisphosphonates. He was also diagnosed with severe Vitamin D deficiency (25 OH Vitamin D less than 18) and started on cholecalciferol 800 IU/day. He was also commenced on cinacalcet, but calcium and PTH levels continue to fluctuate.