Introduction: Hyperparathyroidism is the most common cause of hypercalcemia. We present another endocrine cause for hypercalcemia.
Case report: A 49 year old Afro Caribbean man, previously healthy, was admitted with abdominal pain. He had been complaining of a 2 week history of epigastric pain, loose stools, sweating and shortness of breath. On examination, the patient was unwell, afebrile with epigastric tenderness. Bloods results showed anaemia, Haemoglobin 110 g/l (133180), neutropenia 1.13×109/l (2.07.5), alanine aminotransferase 73 IU/l (756), amylase 821 IU (2512) and calcium 2.68 nmol/l (normal <2.60). He was treated for pancreatitis.
While inpatient, he developed recurrent episodes of chest pain and shortness of breath. Electrocardiogram and serial troponins were normal. CT excluded pulmonary emboli, however showed an incidental diffuse goitre and prominent pancreatic duct. His calcium increased to 3.2 nmol/l and an endocrine review was requested.
By this stage, patient has become markedly confused, agitated, tachypenoic, with a raised JVP, bilateral ankle oedema with profound proximal myopathy, His TSH was fully suppressed with Free T4>103 pmol/l (10.621.0) and Free T3 38 pmol/l (3.25.9). Parathyroid hormone (PTH) was suppressed. Anti thyroid peroxidase antibodies were raised, suggesting Graves disease. A diagnosis of impending thyrotoxic storm, precipitated by pancreatitis and contrast media (Burch-Wartovsky score of 30) was made.
The patient was started on hydrocortisone, propylthiouracil, cholestyramine, propranalol and potassium iodide. He improved remarkably over the next ten days (Free T4 54.1 pmol/l, Free T3 7 pmol/l). Serum calcium, neutropenia and liver function tests (LFTs), had normalised. He was switched to carbimazole while awaiting Radioactive Iodine.
Discussion: Hyperthyroidism can manifest in unusual ways such as chest pain, shortness of breath, altered mental status, as demonstrated in this case. Biochemical abnormalities may include anaemia, neutropaenia, hypercalcaemia and deranged LFTs. Our patient presented with hypercalcaemia and pancreatitis, precipitated by thyrotoxicosis. The treatment of his hyperthyroidism was challenging due to thyrotoxic storm, neutropenia and deranged LFTs.