Frazao J, Coburn JW
Symptomatic hypercalcemia in a diabetic patient undergoing
CAPD: Value of bone biopsy in the diagnosis and management
Am J Kidney Dis
(Nov) 26:831-835 1995
At a time when PTH levels are being extensively used to predict
what type of metabolic bone disease may be present in dialysis
patients, this illustrative case report sounds a note of caution.
The case is that of a 68 year old black dialysis patient who was
being managed on CAPD. He was suffering from dry gangrene of a
toe, and was lethargic and slightly forgetful. White count was
increased. Serum calcium was 10.1 mg/dl and albumin was 1.9
g/dL. He had recurrent sepsis due to gangrene of his feet and
toes. Serum calcium increased to 11.9 mg/dl. Because of low
serum albumin corrected calcium was as high as 14.5 mg/dl. The
hypercalcemia failed to respond to lowering of PD calcium from
3.5 to 2.5 mEq/L. The IRMA PTH level was only 187 pg/ml,
suggesting that hyperparathyroidism was an unlikely cause of his
hypercalcemia. Serum aluminum levels were modest, 41 ng/dl.
The gist of the case is, that the patient underwent bone biopsy
and was found to have severe osteitis fibrosa cystica. The low
IRMA PTH levels were thought to be due to suppression of PTH from
high baseline levels due to the hypercalcemia. The lesson
presented is, that sometimes bone biopsy is indeed necessary to
make a diagnosis in cases of unexplained hypercalcemia.
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