Endocrine Abstracts

A 74 year-old woman had 4 presentations to the hospital with severe symptomatic hypercalcemia despite intensive medical therapy. She had a background of right hemithyroidectomy, hypothyroidism and rheumatoid arthritis. She first presented with symptoms of muscle weakness, vomiting, confusion and muscle aches. Her initial test results showed an adjusted calcium level of 3.79 mmol/l and PTH of 28.1 pmol/l; she was treated with IV fluids, Pamidronate 60 mg and discharged home with an adjusted calcium of 3.04 mmol/l. The neck ultrasound showed a 1.9 cm spongiform intra-thyroid nodule in the anterior aspect of the left thyroid gland. Her initial tests showed a serum creatinine of 93umol/l, urine creatinine of 6.2 mmol/l, urine calcium of 5.90 mmol/l and calcium:creatinine ratio of 0.025. Her vitamin D level was 77 nmol/l. The SPECT/MIBI scan of her parathyroid reported an increased uptake in the lower pole of the left thyroid; suspicious for a parathyroid adenoma. A CT 4D parathyroid with contrast also showed an enlarging lesion in the inferior pole of the left thyroid. She was waitlisted for a parathyroidectomy after discussion at the parathyroid MDT. 3 months after her first presentation, she presented to the hospital with an adjusted calcium of 3.69 mmol/l and was treated with Cinacalcet 60 mg BD and IV fluids. Her adjusted calcium improved to 2.9 mmol/l until she required a further 2 admissions within the subsequent 2 months. Despite Cinacalcet titration, she developed an adjusted calcium as high as 4.82 mmol/l, phosphate of 1.33 mmol/l, creatinine of 153umol/l and PTH of 38 pmol/l. She required urgent renal replacement therapy for her resistant hypercalcemia on both occasions. She remained in the hospital for over a month until she underwent a parathyroidectomy 6 months after her first presentation. Her biopsy results confirmed a parathyroid adenoma and her calcium improved to 2.41/mmol/l after the procedure.