61-year-old previously fit and healthy female presented with one-week history of confusion and altered consciousness. There was no history of fever, headache or limb weakness. She was dehydrated, Glasgow Coma Scale score was 11/15, pupils were equal and reactive to light bilaterally and rest of examination was unremarkable. Initial investigations are outlines in Table 1. X-ray-chest showed mediastinal lymphadenopathy and CT head was unremarkable. She was initially treated for sepsis and dehydration, but the clinical condition deteriorated over the next 48 h. Lumbar puncture and MRI brain performed after neurology consult which were unremarkable. Three days post admission; she also had bone profile, which showed very high calcium levels (5.86 mmol/l). Calcium had not been checked since admission. Further workup of hypercalcaemia is shown in Table 2. A CT chest/abdomen/pelvis showed bilateral hilar, mediastinal and abdominal lymphadenopathy. Bone marrow biopsy confirmed adult T-cell lymphoma on histology. She was treated with intravenous fluids, steroids initially and later commenced on chemotherapy with rapid improvement in her confusion and calcium levels.
|C-Reactive Protein||6.1||1.501.72 mPA|
|White cell count||18.6||3.810.8×109/l|
|Adjusted Calcium||5.83||2.22.6 mmol/l|
|Alkaline phosphatase||217||20140 U/l|
|Parathyroid hormone||1.2||1.66.9 pmol/l|
|1,25(OH) vitamin D||39||20120 pmol/l|
|Angiotensin converting enzyme||85||852 u/l|
Conclusion: Hypercalcaemia is well-known to cause confusion and should be checked when other common causes of confusion are not present. Adult T-cell Lymphoma is a rare cause of calcitriol-mediated hypercalcaemia and responded well to steroids and cancer chemotherapy. Normal 1,25(OH) Vitamin D levels do not necessarily exclude granulomatous diseases in the investigation of non-Parathyroid hypercalcaemia.