Coexistence of primary hyperparathyroidism and multiple myeloma is very rare.
Case report: 45 year old Jamaican female presented with left sided chest pain for a month. CXR showed a pathological left clavicular fracture with a lytic lesion. She was noted to have a serum Ca of 3.26 mmol/l.
Other investigations: Haemoglobin 115 g/l (115155), creatinine 76 umol/l (4992), Corrected Ca 3.26 mmol/l (2.202.60), Phosphate 0.60 mmol/l (0.871.45), PTH 16.8 pmolL (1.66.9), Vitamin D 26 nmol/l (Insufficient if 2575); Paraprotein not detected, kappa light chains 44 mg/l (3.319.4 mg/l), lambda light chains 8.5 mg/l (5.726.3 mg/l), kappa lambda ratio 5.2 (0.261.65), urine-BJP negative and beta-2 microglobulin 4.3 mg/l (0.261.65), LDH 180 IU/l (135214).
Bone marrow: 80% plasma cells on trephine with findings consistent with high risk myeloma.
CT CAP: Expansile lytic lesion in left clavicle, probable pathological fracture of right fourth rib, multiple lytic lesions in bones and calculus in right kidney.
MRI spine showed an abnormal signal in multiple vertebrae.
US Neck: 1.2 low density structure highly suspicious of enlarged parathyroid gland.
Parathyroid Sestamibi : Adenoma in the region of the upper pole of the left thyroid lobe. Patient was diagnosed with Oligo-secretory Myeloma, revised ISS stage two. She completed 6 cycles of chemotherapy and received monthly Zoledronic acid. She is awaiting stem cell transplant.
PET scan post-chemotherapy showed response to treatment with low-grade mild activity in left clavicle only. The patient was referred for Parathyroidectomy.
Discussion: Hypercalcemia as a presenting symptom of concomitant MM and Hyperparathyroidism is rare with 30 reported cases (Hussain et al. 2013). Majority were female with age ranging from 45 to 92 years. Our patient is the youngest to our knowledge. Parathyroidectomy, chemotherapy, and radiotherapy have been used for treatment with variable success. The prognosis has been generally poor with 28% dying within 5 years of diagnosis.