The irrational yet irrestible urge to know or make known. The CC is a "club" founded by a small group of medical professionals, who have made a pastime of turning medical cases and discussions into medically irrelevant history lessons, philosophical rants, and displays of one-upsmanship. The official premise, since the "club" was named, has been to exchange and discuss various books, movies, and ideas. Sometimes we eat sushi.
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.
15 Comments:
1)sarcoidosis 2)metastatic cancer
I am going with 1) especially since I have seen salivary glands.
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Great image by the way!
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.
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.
By the way these letters on "word verification" are getting harder and harder. Can't we get the computer to do this for us?
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."
If you could get a computer to take care of the word verification for you, you would be a spamming deity.
Well, I wouldn't think we were a parathyroidectomy capital of the MidSouth but I was told we had the PTH assay available here.
If you can't get the computer to do the word verification, how about Henry helping.
Dave.
You have a Parathyroid tumor. PtH will rise and fall like the canadian dollar.
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
David,
Forgot to ask you what your PTH levels were cause you can have elevated calcium with a normal PTH.
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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