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GRAND ROUNDS A Woman with Low Energy and High Calcium Susan Spratt, MD The Patient A successful businesswoman�and partner in a major Northi Carolina consulting firm�often worked 60 hours/week, traveling intercontinentally and raising a family of three children. But, at the age of 47, she found herself physically and emotionally exhausted. She was surprised by her increasing fatigue and emotional lability because previously, she said, "it had taken a lot to rattle me." She saw a doctor who told her everything "checked out," and several months later a second physician suggested trying an antidepressant. Before filling the prescription, she decided she needed a life change. She enrolled in Duke University's Rice Diet Program where routine blood tests revealed a markedly elevated calcium of 14.7 mg/dL (normal, 8.7-10.2). She was sent to the Emergency Room where her history was vague and difficult to elicit and she seemed mentally "dull," given her record of work accomplishments. There was a barely palpable mass low in the left anterior neck, just above the clavicle. In the ER, her calcium had risen to 15.7, serum phosphorus concentration was 1.9 mg/dL (normal, 2.3-4.3), and serum concentration of intact parathyroid hormone was 571 pg/mL (normal, 12-72). She was admitted for aggressive intravenous hydration and diuresis with furo-semide. A radioactive sestamibi scan was compatible with a single adenoma in the inferior left parathyroid gland (see Figure). Although patients with hypercalcemia may have symptoms, often the practitioner stumbles on an elevated calcium during laboratory screening of an asymptomatic patient. Indeed, review of our patient's health history revealed that she had undergone such testing 10 months earlier, at which time her calcium was 12.8 mg/dL (lab normal, 8.5-10.6) and Dr. Spratt is in the Division of Endocrinology at Duke University IVIedical Center. She can be reached at Box 3021, DUMC, Durham 27710. phosphorus 2.5 mg/dL (lab normal, 2.5-4.5). Nothing was done then, in part because she offered no complaints and in part because the abnormal screening test result, being unanticipated, was not acted upon. This paper will review the evaluation and management of hypercalcemia and primary hyperparathyroidism, the most common cause of hypercalcemia in the outpatient setting. Pathophysiology of Hypercalcemia About 50% of serum calcium circulates ionized and unbound, 10% is complexed with serum citrate and phosphate, and 40 % is bound to serum proteins.' Under normal conditions, parathyroid hormone (PTH) maintains serum calcium concentration within narrow limits by regulating intestinal and renal absorption of calcium and mobilization from the skeleton (where 99% of total body calcium is stored). PTH secretion is stimulated by low serum concentrations of calcium and inhibited by high concentrations. Within minutes of its release, PTH increases reabsorption of calcium by the kidney, promotes renal wasting of phosphate, and increases resorption of bone by stimulating osteoclast activity. PTH activates Vitamin D. thereby increasing gut absorption of calcium. Blood calcium levels exceed normal when increased bone resorption or increased gut absorption of calcium exceeds the ability of the kidneys to excrete or bone to absorb the excess.- The etiology of hypercalcemia is therefore linked to one of four mechanisms: (1) increased bone resorption; (2) excess intestinal absorption, usually vitamin D-related; (3) impaired renal excretion, including renal failure; or (4) excess PTH secretion, which simultaneously activates mechanisms 1-3. In 80% of cases, primary hyperparathyroidism is caused by a solitary, benign adenoma.'"* A clone of parathyroid gland chief cells expands and loses its ability to sense calcium, causing inappropriate secretion of PTH.' The remaining 414 NCMJ Jantian/Febntan' 2000, Volume 61 Number 1
Object Description
Rating | |
Fixed Title * | NCHH-17: North Carolina Medical Journal [1940-2001] |
Document Title | North Carolina Medical Journal [1940-2001] |
Subject Topical Other | Public Health -- Periodicals.; Physicians -- North Carolina -- Directory.; Societies, Medical -- North Carolina -- Periodicals. |
Description | Includes Transactions of the Society, -1960; 1961- , Transactions issued separately, bound in.; Includes Transactions of the auxiliary to the Medical Society of the State of North Carolina and Proceedings of the North Carolina Public Health Association. Official organ of the Medical Society of the State of North Carolina, 1940-May 1972; of the North Carolina Medical Society, June 1972-. Vols. for 1940-May 1972 published by the Medical Society of the State of North Carolina; June 1972- by the North Carolina Medical Society. |
Contributor | Medical Society of the State of North Carolina. Transactions.; Medical Society of the State of North Carolina.; North Carolina Medical Society.; North Carolina Medical Society. Transactions.; North Carolina Public Health Association. Proceedings. |
Publisher | [Winston-Salem] : North Carolina Medical Society [etc.], 1940- |
Repository | University of North Carolina at Chapel Hill. Health Sciences Library. |
Host | University of North Carolina at Chapel Hill |
Date | 2000 |
Identifier | NCHH-17-061 |
Form General | Periodicals |
Language | English |
Rights | This item is part of the North Carolina History of Health Digital Collection. Some materials in the Collection are protected by U.S. copyright law. This item is presented by the Health Sciences Library of the University of North Carolina at Chapel Hill for research and educational purposes. It may not be republished or distributed without permission of the Health Sciences Library. |
Digital Collection | North Carolina History of Health Digital Collection |
Sponsor | The North Carolina History of Health Digital Collection is an open access publishing initiative of the Health Sciences Library of the University of North Carolina at Chapel Hill. Financial support for the initiative was provided in part by a multi-year NC ECHO (Exploring Cultural Heritage Online) digitization grant, awarded by the State Library of North Carolina, and funded through the Library Services and Technology Act (LSTA). |
Volume Number | 61 |
Health Discipline | Medicine |
Digital Format | JPEG 2000 |
Print / Download PDF Version | http://archives.hsl.unc.edu/nchh/nchh-17/nchh-17-061.pdf |
Document Sort | all; nchh-17 |
Volume Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/identi/searchterm/NCHH-17-061 |
Title Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/documa/searchterm/NCHH-17 |
Catalog Record link | http://search.lib.unc.edu/search?R=UNCb1306322 |
Revision History | done |
Description
Fixed Title * | Page 414 |
Document Title | North Carolina Medical Journal [1940-2001] |
Subject Topical Other | Public Health -- Periodicals.; Physicians -- North Carolina -- Directory.; Societies, Medical -- North Carolina -- Periodicals. |
Description | Includes Transactions of the Society, -1960; 1961- , Transactions issued separately, bound in.; Includes Transactions of the auxiliary to the Medical Society of the State of North Carolina and Proceedings of the North Carolina Public Health Association. Official organ of the Medical Society of the State of North Carolina, 1940-May 1972; of the North Carolina Medical Society, June 1972-. Vols. for 1940-May 1972 published by the Medical Society of the State of North Carolina; June 1972- by the North Carolina Medical Society. |
Contributor | Medical Society of the State of North Carolina. Transactions.; Medical Society of the State of North Carolina.; North Carolina Medical Society.; North Carolina Medical Society. Transactions.; North Carolina Public Health Association. Proceedings. |
Publisher | [Winston-Salem] : North Carolina Medical Society [etc.], 1940- |
Repository | University of North Carolina at Chapel Hill. Health Sciences Library. |
Host | University of North Carolina at Chapel Hill |
Date | 2000 |
Identifier | NCHH-17-061-0050 |
Form General | Periodicals |
Page Type | all; article; article title |
Language | English |
Rights | This item is part of the North Carolina History of Health Digital Collection. Some materials in the Collection are protected by U.S. copyright law. This item is presented by the Health Sciences Library of the University of North Carolina at Chapel Hill for research and educational purposes. It may not be republished or distributed without permission of the Health Sciences Library. |
Filename | northcarolinamed612000_0050.jp2 |
Digital Collection | North Carolina History of Health Digital Collection |
Sponsor | The North Carolina History of Health Digital Collection is an open access publishing initiative of the Health Sciences Library of the University of North Carolina at Chapel Hill. Financial support for the initiative was provided in part by a multi-year NC ECHO (Exploring Cultural Heritage Online) digitization grant, awarded by the State Library of North Carolina, and funded through the Library Services and Technology Act (LSTA). |
Volume Number | 61 |
Issue Number | 1 |
Page Number | 414 |
Health Discipline | Medicine |
Full Text | GRAND ROUNDS A Woman with Low Energy and High Calcium Susan Spratt, MD The Patient A successful businesswoman�and partner in a major Northi Carolina consulting firm�often worked 60 hours/week, traveling intercontinentally and raising a family of three children. But, at the age of 47, she found herself physically and emotionally exhausted. She was surprised by her increasing fatigue and emotional lability because previously, she said, "it had taken a lot to rattle me." She saw a doctor who told her everything "checked out" and several months later a second physician suggested trying an antidepressant. Before filling the prescription, she decided she needed a life change. She enrolled in Duke University's Rice Diet Program where routine blood tests revealed a markedly elevated calcium of 14.7 mg/dL (normal, 8.7-10.2). She was sent to the Emergency Room where her history was vague and difficult to elicit and she seemed mentally "dull" given her record of work accomplishments. There was a barely palpable mass low in the left anterior neck, just above the clavicle. In the ER, her calcium had risen to 15.7, serum phosphorus concentration was 1.9 mg/dL (normal, 2.3-4.3), and serum concentration of intact parathyroid hormone was 571 pg/mL (normal, 12-72). She was admitted for aggressive intravenous hydration and diuresis with furo-semide. A radioactive sestamibi scan was compatible with a single adenoma in the inferior left parathyroid gland (see Figure). Although patients with hypercalcemia may have symptoms, often the practitioner stumbles on an elevated calcium during laboratory screening of an asymptomatic patient. Indeed, review of our patient's health history revealed that she had undergone such testing 10 months earlier, at which time her calcium was 12.8 mg/dL (lab normal, 8.5-10.6) and Dr. Spratt is in the Division of Endocrinology at Duke University IVIedical Center. She can be reached at Box 3021, DUMC, Durham 27710. phosphorus 2.5 mg/dL (lab normal, 2.5-4.5). Nothing was done then, in part because she offered no complaints and in part because the abnormal screening test result, being unanticipated, was not acted upon. This paper will review the evaluation and management of hypercalcemia and primary hyperparathyroidism, the most common cause of hypercalcemia in the outpatient setting. Pathophysiology of Hypercalcemia About 50% of serum calcium circulates ionized and unbound, 10% is complexed with serum citrate and phosphate, and 40 % is bound to serum proteins.' Under normal conditions, parathyroid hormone (PTH) maintains serum calcium concentration within narrow limits by regulating intestinal and renal absorption of calcium and mobilization from the skeleton (where 99% of total body calcium is stored). PTH secretion is stimulated by low serum concentrations of calcium and inhibited by high concentrations. Within minutes of its release, PTH increases reabsorption of calcium by the kidney, promotes renal wasting of phosphate, and increases resorption of bone by stimulating osteoclast activity. PTH activates Vitamin D. thereby increasing gut absorption of calcium. Blood calcium levels exceed normal when increased bone resorption or increased gut absorption of calcium exceeds the ability of the kidneys to excrete or bone to absorb the excess.- The etiology of hypercalcemia is therefore linked to one of four mechanisms: (1) increased bone resorption; (2) excess intestinal absorption, usually vitamin D-related; (3) impaired renal excretion, including renal failure; or (4) excess PTH secretion, which simultaneously activates mechanisms 1-3. In 80% of cases, primary hyperparathyroidism is caused by a solitary, benign adenoma.'"* A clone of parathyroid gland chief cells expands and loses its ability to sense calcium, causing inappropriate secretion of PTH.' The remaining 414 NCMJ Jantian/Febntan' 2000, Volume 61 Number 1 |
Digital Format | JPEG 2000 |
Print / Download PDF Version | http://archives.hsl.unc.edu/nchh/nchh-17/nchh-17-061.pdf |
Document Sort | all; nchh-17 |
Article Title | A Woman With Low Energy And High Calcium |
Article Author | Susan Spratt |
Volume Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/identi/searchterm/NCHH-17-061 |
Title Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/documa/searchterm/NCHH-17 |
Catalog Record link | http://search.lib.unc.edu/search?R=UNCb1306322 |
Revision History | done |
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