Endocrine Abstracts

Introduction: Hypercalcemia is one of the most common endocrine disorders. Most out-patients’s cases are due to primary hyperparathyroidism and run with chronic and low-moderate hypercalcemia. We report a case of acute and severe hipercalcemia of unknown origin. Diagnostic procedure is discussed.

Case report: A 53-year-old man was admitted to the Intensive Care Unit due to progressive deterioration of consciousness in the last 48 hours, associating respiratory failure that required orotracheal intubation. Medical history, collected to his relatives, revealed that the patient was heavy smoker and, had suffered from lumbar pain resistant to analgesia, for the last 2 months. Admission laboratory routine highlighted impaired renal function, a marked neutrophil leukocytosis and acute phase reactants elevation. A cranial and thoraco-abdominal CT scan was performed, which showed a right basal pulmonary condensation without masses or pathological enhancements as well as a crushing L4-fracture. A 12 mm neck nodule was observed under the right thyroid lobe suggesting a possible parathyroid adenoma. An extremely high serum calcium levels (19.3 mg/dl) was detected afterwards. Before the analytical and radiological findings, Endocrinology Unit was consulted for study and treatment of probable parathyroid crisis. Expanded study of phospho-calcium metabolism showed, in addition to hypercalcemia, lower-normal i-PTH levels (15.1 pg/ml, N: 15 – 68.3 pg/ml), decreased levels of 25-OH vitamin D (7.8 ng/ml, N> 30 ng/ml), hypercalciuria (792 mg/24 h) and hypophosphaturia (0.38 g/24 h). These findings led to determine PTHrp levels which were high (5.7 pmol/l, normal <2.0 pmol/l). A cervical ultrasound identified the cervical nodule as adenopathy. After dialysis and zoledronate, hypercalcemia was reversed. Among studies searching for hidden neoplasia, only a bone marrow biopsy revealed infiltration by squamous cell carcinoma without being able to demonstrate the primary tumor by any other test.

Conclusions: Hypercalcemia is a common analytical finding and requires an adequate etiological characterization for an adequate diagnostic and an adequate therapeutic planning. We highlight the unusual observation of a severe and acute hypercalcemia development as the primary presentation of a neoplasm whose primary location could not be evident.