Endocrine Abstracts

Case history: 80 year old male was referred to endocrine clinic for incidental hypercalcemia picked up on six monthly blood tests for follow up of treated carcinoma of prostate in remission. Patient himself complained only of mild mechanical backache and no other symptoms of hypercalcemia. There was no family history of thyroid or parathyroid related disorders. Drug history did not include thiazides or lithium.

Investigations: serum calcium 2.75 mmol/l, PTH 30.4 pmol/l, Vitamin D 27.7 nmol/l, PSA 0.51 microgram/l Normal ALP, Phosphate and kidney function. 24 hr urinary calcium output 4.92 mmol/l. X-ray pelvis and lumbosacral spine showed osteoarthritic changes but no fracture or bony lesion. No renal calculi on CT KUB. No osteoporosis on DEXA scan. normal serum protein electrophoresis.

Treatment and Follow up:: Initially managed conservatively with six monthly serum calcium and renal functions along wit vitamin D supplementation and advice on optimal fluid intake. Serum calcium at one year follow up was 2.88 mmol/l with normal renal functions. He was admitted two months later following a mechanical fall with long lie leading to rhabdomyolysis and AKI. Biochemistry revealed serum calcium 5.16 mmol/l, PTH 245 pmol/l, creatinine 178 micromol/l, urea 24 nmol/l, eGFR 32 and CK 2792 U/l. Repeat ultrasound KUB and x-rays of pelvis and lumbosacral spine did not reveal any abnormality. He was managed with intravenous pamidronate and fluids which reduced serum calcium to 2.8 mmol/l, PTH 36.3 pmol/l and eGFR improved to 47. He was further referred to surgeons for consideration of parathyroidectomy. An ultrasound and CT neck revealed right inferior parathyroid adenoma with normal thyroid gland and no evidence of cervical lymphadenopathy. parathyroidectomy was done three months after hospital admission. He made an uneventful post operative recovery. Histology of removed gland revealed parathyroid adenoma. Follow up in endocrine clinic six months after surgery revealed a serum calcium of 2.42 mmol/l, PTH 15.8 pmol/l and vitamin D 53 nmol/l.

Conclusion and Points for Discussion: Rarely, Primary Hyperparathyroidism may present with parathyroid (hypercalcemic) crisis, which may occur due to significant fluid loss or dehydration leading to rapid rise in blood calcium. Patients may experience cardiac and renal impairment, rapid deterioration of CNS, vomiting, severe abdominal pain, stomach ulcers and constipation. High index of clinical suspicion is required in acutely ill patients as presentation is varied and mortality is high in patients treated only conservatively. Prompt surgical intervention should be considered as treatment of choice.