Wednesday, March 22, 2006

Hypercalcemia with a normal PTH

Here is a coronal view (of the head, neck, chest) of a sestamibi scan in a 60 year old woman with hypercalcemia. Her parathyroid hormone level was normal. What's going on?

Here's some more delayed images, which I have posted after joe made guess 1 and 2 in the first comment.

posted by Clay @ 3/22/2006 08:21:00 AM   16 comments

16 Comments:

At 5:47 PM, Blogger joe said...

1)sarcoidosis 2)metastatic cancer

 
At 3:38 PM, Blogger joe said...

I am going with 1) especially since I have seen salivary glands.

 
At 3:39 PM, Blogger joe said...

This comment has been removed by a blog administrator.

 
At 5:24 PM, Blogger joe said...

Great image by the way!

 
At 9:32 PM, Blogger Clay said...

The radiologist's reading was that this scan was consistent with a left inferior parathyroid adenoma.

From emedicine.com:
"The causes of hypercalcemia that result in a concomitantly elevated PTH level are few. These include familial benign (hypocalciuric) hypercalcemia (FHH), lithium-induced hypercalcemia, and tertiary hyperparathyroidism. A cautionary note is that a minority of patients (ie, 10-15%) with hyperparathyroidism have PTH levels at the high end of the reference range, which is inappropriately high in the presence of elevated calcium."


Her initial high-normal PTH level several months earlier threw me off the trail, then she never followed up with me in the clinic again until she started having trouble again. I had to use the C word to get her to follow it through this time.

 
At 6:18 AM, Blogger joe said...

I am missing something or confused. If you are hypercalcemic and have a increased PTH then you have a adenoma of your parathyroid glands until proven otherwise. Your case was hypercalcemia with a normal PTH.(now I see you are saying "high normal").
You quote emedicine to say that there are few causes that cause increased calcium and increased PTH. Where is parathyroid adenoma? I think I see you are saying that a "high normal PTH in face of hypercalcemia is an adenoma also". I can understand this.

When I was discussing another case with a surgeon regarding parathyroid glands. He noted that when he was searching for and thought he had removed an adenoma, he drew a immediate PTH. As SOON as the correct gland(with adenoma) was removed there was a IMMEDIATE drop in PTH.

 
At 6:20 AM, Blogger joe said...

By the way these letters on "word verification" are getting harder and harder. Can't we get the computer to do this for us?

 
At 6:45 AM, Blogger Clay said...

That is what confused me and that is why I am presenting the case. If someone has hypercalcemia, (for non adenoma reasons) the PTH should be suppressed. This lady had a PTH within the normal refernce range, but it was on the high end. She was definitely symptomatic, so I went ahead and imaged her. I have an algorithm that I may scan and post that shows how to work this up (I didn't first check a 24 hour urine calcium to rule out FHH as recommended).

Our friend the cranial orifice and neck surgeon told me about the intraoperative PTH assay. That is not available at his hospital. Here is what emedicine says about it:
"For this purpose, many centers have begun to use the intraoperative PTH assay. Because the plasma half-life of PTH is only approximately 4 minutes, the level falls quickly after resection of the source. If the level fails to fall after resection of the identified abnormal gland, the procedure is extended to allow for further exploration. However, the intraoperative PTH assay is expensive and is usually available only in centers that perform a high volume of parathyroidectomies."

 
At 6:50 AM, Blogger Clay said...

If you could get a computer to take care of the word verification for you, you would be a spamming deity.

 
At 9:02 AM, Blogger joe said...

Well, I wouldn't think we were a parathyroidectomy capital of the MidSouth but I was told we had the PTH assay available here.

 
At 9:03 AM, Blogger joe said...

If you can't get the computer to do the word verification, how about Henry helping.

 
At 9:14 AM, Blogger Americanist 1 said...

My name is David,

I am not a doctor, but found this post and wondering if you have any suggestions.

I am currently suffering from Hypercalemia as well. I am 35. My PTH levels are normal. I have been checked for various forms of cancer and none has been found. I have taken a round of predizone to determine if it was sarcoidosis, which failed.

On a daily basis i have numbness and tingling in my arms, hands, legs and feet, especially when I wake in the night or morning. I also suffer from anxiety attacks which I think are related to abnormal heart rythms due to the hypercalcemia.

My hypercalcemia was initially discovered when I was 19 in 1989, but a pannel of doctors dismissed it as abuse of vitamin D and told me to drink lots of water.

In 1997 I had surgery to remove a kidney stone that was lodged in my ureter. I currently have several existing stones.

My doctor also checked my PH balance and it was normal so Renal Tubular Acidosis can be ruled out.

I am running out of options.

Do you have any suggestions?

Thanks

 
At 4:16 PM, Blogger ertertert said...

Dave.

You have a Parathyroid tumor. PtH will rise and fall like the canadian dollar.

 
At 9:12 PM, Blogger Kodger99 said...

David,

My name is Greg and I had and seem to be once again getting hypercalcemia (mild) with a high end normal PTH. The two = 2 adenomas. They were taken out!
Now, 1 yr later my calcium ( and when I refer to calcium, it's always ONLY been my ionized calcium ) that is slightly elevated with a PTH either top end of normal to just over. PTH is never below 40........that's with only 2 remaining parathyroid glands.
Do you get any mucle fatigue? General weakness?

Greg

 
At 8:03 PM, Blogger Kodger99 said...

David,

Forgot to ask you what your PTH levels were cause you can have elevated calcium with a normal PTH.

 
At 1:27 PM, Blogger Chris Orchard said...

Hi. In the early exploratory stages of what is causing my hypercalcemia. Ionized Calcium is 5.8 and serum Calcium has fluctuated from 10.6-10-10.3 over the last 9 months. PTH is now 49.1 but has been 54. Am getting muscle aches in triceps for last 4 weeks. Am also getting tingling all over. Doctors now doing chest x-ray but seem reluctant to do anything else except re-test. Also my vitamin D level is 18. Instinctively am convinced it is parathyroid. Any ideas?

 

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