Hypercalcemia due to Primary Hyperparathyroidism

Author: V. Dimov, M.D., Cleveland Clinic
Reviewer: S. Randhawa, M.D.

A 58-year-old woman has elevated calcium levels detected incidentally during workup for high blood pressure. The patient denies prior personal or family history of endocrine disease or exposure to head and neck radiation. She complains of fatigue and musculoskeletal aches.

PMH:
HTN, CAD S/P stent in RCA 1 yr ago

Medications:
Metoprolol, lisinopril, ASA, Plavix, Tylenol

Physical examination:
BP 160/100
Thin-appearing woman who looks clinically euthyroid.
Head and neck exam reveals a supple neck without palpable thyromegaly or lymphadenopathy.

Office ultrasound was performed to see a normal thyroid in size and appearance. Two areas of parathyroid abnormality were detected.

What tests would you order?
Repeat Ca++ level
24-hour urinary calcium
PTH, PTHrP
Vit D metabolites
TSH
CXR
EKG


BMP and endocrine work-up

Her calcium levels have been as high as 12.8, associated with intact PTH level of 160, phosphorous 2.7, and 25-hydroxy vitamin D level 18.8. Her TSH is normal at 1.7. Twenty-four-hour urinary calcium collection is 153 mg/24-hours, and her urinary NTX is 93, which is elevated. Her vitamin D-1,25 level is elevated at 85.

She has significant osteoporosis.


EKG

Would you order any additional tests?
A subtraction sestamibi scan showed a larger signal on the right and a smaller signal in the left lower parathyroid gland positions.


Parathyroid sestamibi scan


Sestambi report

Final diagnosis:
Clear biochemical evidence of primary hyperparathyroidism and undesirable consequences such as high calcium levels and osteoporosis.

The patient has clear indications for parathyroid surgery and was referred accordingly.

References:
Hypercalcemia. eMedicine.
QT Interval. Family Practice Notebook.

Related:
High blood calcium tied to lethal prostate cancer. Reuters, 09/2008.

Published: 03/12/2006
Updated: 09/03/2008

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