An 80 year old patient was diagnosed with asymptomatic, mild primary hyperparathyroidism in 2005 and managed conservatively with regular biochemical monitoring. Other medical history included atrial fibrillation, hypertension, CKD stage 3, type 2 diabetes and memory impairment. In 2011, in view of increasing calcium, he was referred to the endocrine surgeons to consider parathyroidectomy. A very low 25 (OH)vit D (12 nmol/L) prompted high dose oral cholecalciferol treatment. This precipitated a significant rise in serum calcium necessitating admission. During this admission, he was found to have low PTH and was investigated for other causes for hypercalcaemia. Investigations See the table attached Normal bone scan, PSA, Myeloma screening and negative Quanteferon TB test Serum ACE level - 118 (normal 1268 IU/L), PTHrp - <0.7 pmol/L Chest x-ray - Patchy opacification at left lung base CT scan - Multiple mediastinal lymphadenopathies with bilateral pleural effusion. No definite evidence of malignancy Pleural fluid- No evidence of malignant cells Brochoscopy - Normal bronchial tree and endobronchial mucosal biopsy showed granulomas. Mediastinoscopy and lymph node biopsy showed abundant non casseating granulomas consistent with sarcoidosis. No evidence of malignancy or fungal or mycobacterial infection. Results and Treatments Initially he was treated with intravenous hydration and bisphosphonate infusion. Oral prednisolone was started on 18/8/2011, after lymph node biopsy confirmed sarcoidosis. Conclusion and Points for discussion 1) Our case demonstrates the co-existence of primary hyperparathyroidism and sarcoidosis and the suppressibility of PTH secretion in primary HPT. 2) Acute severe hypercalcemia can be precipitated with loading dose vitamin D treatment in patients with sarcoidosis, where there is an intrinsically high 1-α hydroxylase activity.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.