Unusual case of coexisting primary hyperparathyroidism and sarcoidosis presenting with severe hypercalcemia

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: MON 199-237-Disorders of Parathyroid Hormone & Calcium Homeostasis
Monday, June 17, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board MON-218
Tim Arakawa*, Jan M Bruder, Devjit Tripathy and Maureen Koops
University of Texas Health Science Center at San Antonio, San Antonio, TX
Introduction: Most patients with primary hyperparathyroidism (PHPT) present in the outpatient setting with mild to moderate hypercalcemia. However, cases of severe hypercalcemia with elevated PTH may be secondary to multiple etiologies. We present a rare case of severe hypercalcemia, elevated PTH and sarcoidosis.

Clinical Case: A 62-year-old woman was admitted with severe hypercalcemia. Her presenting symptom was constipation for the past month with no relief from over-the-counter medications or enemas. She also complained of lightheadedness, fatigue, chills, lethargy, and poor appetite. Her only calcium intake was an over-the-counter calcium supplement and she had recently been started on HCTZ. She had lost 11 lbs in the previous 9 months but otherwise had no history of tuberculosis, fractures, kidney stones, cancer, or immobilization or antacid ingestion. Family history was significant for kidney stones and cancer. Initial corrected calcium level was 16.2 mg/dL (8.2-10.3 mg/dL) with an inappropriately normal PTH of 24 pg/mL (11-67 pg/mL), consistent with a PTH-mediated process. Urinary calcium was 483 mg/24 hrs (40-320 mg/24 hrs). The 25-hydroxy Vitamin D level was 19 ng/mL (30-80 ng/mL), and 1,25-dihydroxy Vitamin D3level was 63 pg/mL (15-75 pg/mL). Magnesium level was 1.8 mg/dL (1.6-2.2 mg/dL). Serum TSH, Vitamin A, PTHrp levels and SPEP were normal and a workup for malignancy was negative. A subsequent sestamibi SPECT/CT scan showed a right parathyroid adenoma located just inferior to the right thyroid lobe. CT of the chest revealed mediastinal lymphadenopathy and right upper lobe interstitial opacities concerning for granulomatous disease. Transbronchial biopsy of a mediastinal lymph node showed benign bronchial mucosa with noncaseating granulomas. Prior to the biopsy, calcium supplementation and HCTZ were discontinued. The hypercalcemia was treated with IV fluids, and bisphosphonate therapy was not required. After diagnosis with sarcoidosis, the patient was started on prednisone with resolution of her hypercalcemia.

Conclusion: It is unusual for patients with PHPT to present with severe hypercalcemia requiring hospitalization. In cases of severe hypercalcemia, elevated serum calcium and PTH levels should not preclude a more comprehensive workup for non-PTH-mediated hypercalcemia.

Nothing to Disclose: TA, JMB, DT, MK

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