Hypercalcemia due to Primary Hyperparathyroidism

87 yo AAF is complaining of joint pain affecting both knees and hands for several months.

PMH: HTN, DM2, COPD, OA, Hypothyroidism

Medications: HCTZ, Glipizide, Tylenol, Ultram, Synthroid, Aerosols, ASA, Oscal and Vit. D

Physical exam:
WD/WN in NAD
VSS
Extremities: Chronic DJD changes

What tests would you order?
X-rays
CBCD, CMP
UA

CMP shows hypercalcemia.


CMP in hypercalcemia


Ca++ levels over the last 3 years

What is the reason for her hypercalcemia?
Ca++ supplements and vit. D?
HCTZ?

She takes HTCZ which was stopped and substituted with a CCB but the hypercalcemia persisted.

What is the next step?
PTH

PTH level is high and the diagnosis is primary hyperparathyroidism. TSH is normal - this is important because thyrotoxicosis can cause hyperalcemia (she takes Synthroid).


PTH level is diagnostic for primary hyperparathyroidism

What happened?
Ordinarily, the treatment is surgical but the patient is 87 and she refused any intervention. The calcium supplements, vit. D and HCTZ will be stopped and her calcium level will be monitored.

Final diagnosis: Hypercalcemia due to primary hyperPTH


Hypercalcemia due to hyperparathyroidism (second case)


CMP


References:

Mnemonic for DDx of Hypercalcemia - VITAMIN TRAPS:

Vitamin A and D intoxication
Immobilization
Thyrotoxicosis
Addison's disease/ Acidosis
Milk-alkali syndrome
Inflammatory disorders
Neoplastic disease
Thiazides, other drugs
Rhabdomyolysis
AIDS
Paget's disease/ Parenteral nutrition/ Parathyroid disease
Sarcoidosis

Source: Medical Mnemonics.com


Pathophysiology of hyperparathyroidism

Source: Pathguy.com