Endocrine Abstracts

Case history: A 54 year old Polish gentleman was admitted to a large northern teaching hospital, with life threatening hypercalcaemia, requiring renal replacement therapy. He presented with extreme fatigue and lethargy, with a significant reduction in mobility and exercise tolerance. Further initial history was hampered by language barrier and an increasingly moribund patient.

Investigations: Base line blood work up revealed stage 3 AKI, with a liver bone profile showing a calcium of 5.06. PTH was then requested showing a level over 300. patient was then referred to the endocrine team. Despite aggressive fluid replacement and IV bisphosphonate treatment, his renal function continued to decline requiring renal replacement. Unfortunately even with renal replacement and falling calcium levels- he developed increased shortness of breath and new oxygen demands- requiring mechanical ventilation. His CXR showed severe ARDS. After a period on ICU he was successfully weaned off the ventilator and stepped down to a ward. Repeat PTH was still nearly 300 and it was thought most likely to be a case of parathyroid malignancy.

Results and treatment: Imaging and uptake scans proved inconclusive- a biopsy did not show any malignancy, and a diagnosis of primary hyperparathyroidism was made. He underwent total Parathyroidectomy- and has had a good recovery- with PTH levels falling to undetectable post-surgery. It later became apparent from his English speaking daughters that he had been taking calcium supplements back in Poland for some time. It is not clear the dose or frequency of the supplements, or whether they were taken in excess. The effects of this supplementation may or may not have contributed to his hyperkalaemia.

Conclusion: It is rare to see such hypercalcaemia and such elevated PTH levels with primary PTHism. We wondered if the initial fluids were the driving force of the ARDS or the hyperkalaemia itself. More evidence is needed to aid treatment and develop fluid regimes in such cases.