Endocrine Abstracts

Background: Hypercalcemia in patients with advanced chronic liver disease (CLD) without hepatic neoplasia is a rarely reported and poorly understood entity. CLD is usually associated with hypocalcaemia because of hypoalbuminemia. Hypercalcemia on the other hand is extremely rare and needs meticulous ruling out of other causes.

Case Report: A 55-year-old male who was admitted with jaundice, weight loss and hypercalcaemia. He had a calcium that peaked at 3.34 with a suppressed PTH (<0.4). Labs revealed worsening liver enzymes. Total bilirubin peaked around 9 days, at 149umol/l, before starting to trend down. He had extensive evaluation of hypercalcemia. He had an urgent CTCAP to look for malignancy which found new diagnosis of liver cirrhosis with multi nodular liver and features of portal hypertension. Focal hepatic abnormality was difficult to exclude with the background of cirrhosis. He went onto have an MRI on which there were no discrete focal liver lesions although there was decompensation with ascites not seen on the first scan few days prior. His vitamin D was low, ruling out parathyroid adenoma or vitamin D toxicity. AFP and ACE levels were normal, as was TSH and T4, ruling out malignancy and hyperthyroidism as etiology. Normal renal function ruled out renal etiology for hypercalcemia. There was no evidence of granulomatous disease. He had raised IgG 21.2 but normal immunoglobulins. Serum electrophoresis and urine BJP were negative. No paraprotein detected, no urinary free light chains. After extensive work-up, no cause was found and he was treated with IV fluids and given an IV infusion of bisphosphonate.

Discussion: Hypercalcemia caused by advanced chronic liver disease in the absence of malignancy is a rare condition. It is a diagnosis of exclusion and responds well to bisphosphonate treatment, leading to resolution of hypercalcemia and prevention of further debility.