Endocrinology- Hypercalcaemia

Question 1

At what concentration of serum calcium does hypercalcaemia occur?

Answer 1

> 2.6mmol/L

Question 2

What are the two common causes of hypercalcaemia?

Answer 2

Primary hyperparathyroidism and malignancy

Question 3

What is typical of PTH levels in primary hyperparathyroidism and malignancy, allowing them to be distinguished between?

Answer 3

Primary hyperparathyroidism- Normal/high PTH

Malignancy- Low PTH

Question 4

What are malignant causes of hypercalcaemia usually associated with?

Answer 4

Squamous cell epithelia tumours- Due to the secretion of PTH-related peptide
Normally large or advanced tumours

Question 5

What 2 other conditions can hypercalcaemia with a low PTH be associated with?

Answer 5

TB or sarcoidosis

Question 6

What is the most common cause of primary hyperparathyroidism?

Answer 6

A single parathyroid adenoma

Question 7

What could parathyroid hyperplasia in more than one gland suggest?

Answer 7

A genetic cause- e.g. multiple endocrine neoplasia

Question 8

What could, in rare cases, a serum calcium concentration of >3.5mmol/L suggest?

Answer 8

Parathyroid cancer

Question 9

What can parathyroid cancer occur in association with? What is the name of the condition?

Answer 9

Jaw tumours - (hyperparathyroidism- jaw tumour syndrome)

Question 10

How is primary hyperparathyroidism discovered?

Answer 10

Mostly asymptomatic, discovered incidentally via blood tests

Question 11

What are the non-specific symptoms of primary hyperparathyroidism?

Answer 11

Tiredness

General aches and pains

Question 12

What are the specific symptoms of primary hyperparathyroidism?

Answer 12

Polyuria
Polydipisa- due to nephrogenic diabetes insipidus
Abdominal pain and constipation
Psychiatric symptoms 
5% get kidney stones

Question 13

What is unique about the appearance of severe metabolic parathyroid bone disease on X-rays?

Answer 13

Classical cystic appearance (‘brown tumour’)

Question 14

What is common of PTH and phosphate levels in primary hyperparathyroidism presenting with hypercalcaemia?

Answer 14

High/non-suppressed PTH

Low phosphate

Question 15

What 2 things does high ALP reflect?

Answer 15

Increased bone turnover

Possible co-existing Vitamin D deficiency§

Question 16

What 3 clinical features may be present in a patient with hypercalcaemia?

Answer 16

• Reduced bone density-especially around distal radius
• Nephrocalcinosis
• Sub-periosteal erosion of the phalanges (in severe cases)

Question 17

What is Familial Hypocalciuric Hypercalcaemia?

Answer 17

Rare condition caused by genetic defect in calcium sensing receptor

Question 18

What distinguishes FHH from primary hyperparathyroidism?

Answer 18

Low urine calcium/ creatinine ratio

Question 19

How is the parathyroid adenoma localised?

Answer 19

Isotope scanning alongside ultrasound or CT

Question 20

At what concentration of serum calcium should surgery be considered for hyperparathyroidism?

Answer 20

> 2.85mmol/L

Question 21

When are patients usually recommended for surgery for hyperparathyroidism?

Answer 21

If symptoms are debillitating
If the patient is young
If the patient presents with severe acute hypercalcaemia

Question 22

If surgery is not desirable, what methods are put in place for hyperparathyroidism?

Answer 22

Medical management / observation

Calcimimetic drugs in order to lower calcium levels

Question 23

What does a patient with acute severe hypercalcaemia present with?

Answer 23

Profound dehydration

Renal impairment