9 June - Hyperparathyroidism

This morniongs case was a quite unusual presentation.  A 28 y/o male was admitted with complaints of dysphagia and odynophagia and had had some concomitant symptoms of headache and photophobia.  He had some neck swelling on examination.  Serum chemistries revealed an unexpected finding of hypercalcemia (Ca >13).  PTH was measured at over 900.  Sestamibi scan revealed significant uptake in the R inferior parathyroid area.

Imortant to differentiate parathyroid carcinoma (rare) from parathyroid adenoma (common).  Features that suggest carcinoma in this case include young age, very high calcium (usually 12 or less with adenoma) and markedly elevated PTH (usually only mildly elevated with adenoma).  This article is a comprehensive review of this rare condition. 

Remember to check PTH on patients with even marginal elevations of serum calcium.  If the PTH is not maximally supressed then you are dealing with hyperparathyroidism.  Undetectable PTH in the setting of hypercalcemia has a more broad differential.  In these cases a search for more rare causes of hypercalcemia can be considered. 

Other pearls from this AM:

Elevated alk phos with normal calcium, phosphate, and LFTs suggests Pagets

Hypercalcemia can cause a short QT interval primarily through shortening of the ST segment.  This can produce findings worrisome for early repolarization vs ST elevation and apparently can mimic MI.