[Malignant humoral hypercalcemia associated with angiotropic large B cell lymphoma]

Angiotropic large B cell lymphoma (angiotropic LCL) or intravascular large cell lymphoma (IVLCL) was diagnosed by liver and bone marrow biopsies and immunohistochemical studies in a 52 year old Caucasian male. IVLCL is a very rare disease characterized by widespread intravascular proliferation of lymphoma cells. Although it most commonly affects the central nervous system or skin and occasionally bone marrow, angiotropic LCL may be present without evidence of localized disease, as seen initially in our patient. To date, only a few cases of intravascular malignant lymphomatosis associated with parathyroid hormone related protein (PTH-rP) induced humoral hypercalcemia have been published. Our extraordinary case was diagnosed mainly by liver biopsy. The neoplastic lymphoid cells stained diffusely and strongly positive with CD-20 (Pan B) and were negative for CD-3 (Pan T) immunostain. The most significant, initial clinical finding was severe, unexplained hypercalcemia (until 18.6 mg/dl). Plasma PTH-rP showed a ten-fold increase at 8 pmol/L (normal value less than 0.8 pmol/L). Very unusual cytogenic abnormalities were found. The patient received the massive third generation combination chemotherapy comprising of Methotrexate, Doxorubicine, Cyclophosphamide, Vincristine, Prednisone and Bleomycin and developed, complete although temporary, clinical, humoral and cytogenetic remission.

Screening for primary hyperparathyroidism (PHPT) in clinic patients: differential diagnosis between PHPT and malignancy-associated hypercalcemia by routine blood tests

Screening for primary hyperparathyroidism (PHPT) by measurement of the serum calcium concentration detects one patient per 500-1000 individuals in Western countries, and one patient per 2500-5000 subjects in Japan. Among clinic patients, however, the presence of many false-positive cases due to malignancy-associated hypercalcemia (MAH) reduces the benefit of such screening. We evaluated a new method of screening for PHPT based on the results of routine blood tests using the hospital information system (HIS) at our hospital. This new method could distinguish PHPT from MAH. This study included 25179 blood samples in which the serum calcium (Ca), albumin (Alb), chloride (Cl) and inorganic phosphate (IP) concentrations had been measured between March, 1994 and February, 1995 at Osaka University Medical Hospital. The HIS was programmed to pick blood samples that satisfied Formula 1 [Ca(mEq/ml) > 0.3 x Alb(g/dl) + 4.1] and Formula 2 ([Cl(mEq/ml)-84] x [10 x Alb-15]/[IP(mg/dl)/3.1] > 400). Of data from 25179 blood samples collected, those from 54 patients satisfied both Formulae 1 and 2. The patients from which these samples were derived from were subject to further analysis: medical records were studied and the intact-parathyroid hormone concentration was measured if necessary. Of these 54 cases, 19 patients (35.2%) were subsequently diagnosed with PHPT, including two, who were newly diagnosed with PHPT by this screening procedure. Although 35 (64.8%) of 54 patients were false-positive, many of them were treated with blood purification therapies in the Department of Pediatrics or the Intensive Care Unit (ICU). On the other hand, there were four false-positive cases (7.4%) caused by MAH. False-negative case in this study was only one patient (5%), whose diagnosis was normocalcemic PHPT. When omitting samples from pediatric patients and those in ICU, this screening procedure for PHPT has the advantage of being able to differentiate this diagnosis from MAH.

[Characteristic features of primary hyperparathyroidism caused by parathyroid cancer--based on 2 cases]

Two cases of women with primary hyperparathyroidism caused by parathyroid cancer were presented. The authors noticed the following characteristic features of primary hyperparathyroidism in the course of the cancer: rich clinical symptomatology usually in form of considerable bone destruction, renal stones and nephrocalcinosis, biochemically very high level of calcium, above 14-16 mg%, threatening with hypercalcemic crisis and considerably higher parathormone serum concentration even up to twenty times above the norm. Parathyroid cancer, more often than adenoma, is a stiff and large neck tumour accessible for palpation. There are no specific biochemical and imagining examination techniques to recognise beyond any doubt the cancer character of primary hyperparathyroidism before operation. The histopathological diagnosis of this cancer is difficult and is not usually done intraoperatively. The recurrences of the malignancy are typical and they require reoperations after stating places of relapse or metastases.

[Hypercalcemia in the elderly]

A COMMON FINDING: Hypercalcemia is not rare among elderly patients. Hyperparathyroidism and neoplasia are the most frequent causes of hypercalcemia in old patients. Symptoms due to hypercalcemia are usually non specific in old subjects, leading to consider easily this diagnosis and to measure plasma calcium level.

DIAGNOSIS

Biological diagnosis of hypercalcemia is not always obvious in old patients because of frequently decreased plasma albumin levels leading to lower plasma total calcium level. Thus, it is always necessary to calculate plasma total calcium level corrected by albumin in order not to underestimate hypercalcemia in elderly subjects.

PROGNOSIS

The short-term risk of hypercalcemia is acute hypercalcemia, which may be lifethreatening. The long-term risk of hypercalcemia is renal failure.

TREATMENT

When hypercalcemia is due to primary hyperparthyroidism, the treatment of choice is surgery. However, for old patients with high surgical risk surgery with local anesthesia or ultrasonically guided percutaneous ethanol injection into parathyroid adenoma can be proposed.

Hypercalcemic crisis

Hypercalcemia may decompensate from a more or less chronic status into a critical and life-threatening condition, hypercalcemic crisis. In the majority of cases, primary hyperparathyroidism is the cause; humoral hypercalcemia of malignancy or rarer conditions of hypercalcemia will decompensate less often. The leading symptoms that characterize the crisis are oliguria and anuria as well as somnolence and coma. After a hypercalcemic crisis is recognized, an emergency diagnostic program has to be followed either to prove or to exclude primary hyperparathyroidism. In the first case, surgical neck exploration is the only way to avoid fatal outcome. The diagnostic program should be performed within hours; during this time, serum calcium should be lowered. Treatment of choice is hemodialysis against a calcium-free dialysate. Bisphosphonates could be useful as adjuvant drugs.

[Life threatening hypercalcemia in a young man with ALL]

HISTORY AND ADMISSION FINDINGS

A 16-year-old man experienced fatigue, vomiting and diffuse abdominal pain. Since 4 days he had myalgia in both arms and legs. On examination only a tachycardia of 110/min was noticed.

INVESTIGATIONS

Laboratory tests revealed hemoglobin 12.7 g/dl, leucocytes 10,300/microliter, platelets 89,000/microliter, LDH 191 U/l, sodium 134 mmol/l, potassium 2.76 mmol/l, calcium 4.52 mmol/l (I), creatinine 1.13 mg/dl, urea 72 mg/dl, uric acid 11.2 mg/dl. The levels of PTH (0 pg/ml), PTH-related peptide, vitamin D, vitamin A, IGF-1, STH, 5-HIES and interleukin 6 were within normal limits. TNF-alpha 25.9 pg/ml (< 8.1). The electrocardiography revealed a sinus rythm with a QT-time of 0.28 s (= 100%). Multiple osteolytic bone leasions were seen in thoracic CT-scan. Abdominal sonography showed normal liver structure, multiple subhepatic lymph nodes without splenomegaly. The cytologic examination of the bone marrow demonstrated a diffuse infiltration by a common acute leukemia.

TREATMENT AND COURSE

The rehydration with physiologic saline (3500 ml/d) was initiated in the ICU. Furosemide was added for further renal excretion. Additionally prednisone (100 mg/d) and calcitonin (300 I.E./d) were given. The calcium level fell within two days. No cardiac arrhythmia nor acute renal failure were seen. After definitive diagnosing the patient was treated corresponding to a specific protocol. One year later the relapsing ALL was diagnosed also by hypercalcemia (5.9 mmol/l). The level of TNF-alpha before and after correction of hypercalcemia was 20 pg/ml.

CONCLUSION

The acute treatment of hypercalcemia is independent of the underlying cause (rehydration with physiologic saline, renal excretion with furosemide, inhibition of osteoclastic activity). The main causes are hyperparathyreoidism or malignancys (90%). We describe TNF-alpha as a possible marker of tumoral load of a common ALL but we are not able to reveal a correlation between TNF-alpha and the calcium level.

Rapidly relapsing squamous cell carcinoma of the renal pelvis associated with paraneoplastic syndromes of leukocytosis, thrombocytosis and hypercalcemia

A case history is reported here in which leukocytosis, thrombocytosis and hypercalcemia associated with rapidly relapsing squamous cell carcinoma (SCC) of the renal pelvis were observed. In a 58-year-old man, SCC of the renal pelvis was documented during nephrolithotomy, and right nephrectomy was performed. Local relapse of the tumor occurred rapidly in 2 months' time and hypercalcemia, leukocytosis and thrombocytosis worsened in accordance with tumor volume. Cranial computerized tomography (CT), thorax CT and bone scintigraphy were negative for metastasis. The serum parathyroid hormone level was 28 pg/ml (normal 9- 55 pg/ml). To disclose leukocytosis and thrombocytosis, peripheral smear and bone marrow aspiration were performed and no pathologic finding regarding any hematologic disorder was found; the samples were also BCR-ABL negative and Philadelphia chromosome negative. Production of several factors by tumor cells may be responsible for this paraneoplastic syndrome. The association of SCC of the renal pelvis with this triple paraneoplastic syndrome is an extremely rare occurrence.

Ergebnisse der bilateralen Operationstechnik bei primärem Hyperparathyreoidismus

AIM OF THE STUDY

The surgical success rate and clinical outcome after surgery for primary hyperparathyroidism were evaluated in a prospective long-term follow-up study.

PATIENTS AND METHODS

407 patients, 396 with the first manifestation, 6 with recurrent and 5 with persistent disease underwent operation from August 1, 1987 to August 15, 1999. All patients were prospectively investigated in a long-term follow-up study and underwent reexaminations at regular surveillance intervals. The postoperative course is known in 93.9% of all patients.

RESULTS

The prevalence of asymptomatic primary hyperparathyroidism was 5.6% in our patients. Surgical cure was obtained in 97.7% of patients after initial neck exploration. In 58% of the patients with hypercalcaemic syndrome recovery occurred within the first month after surgery. Skeletal symptoms persisted in 24% of patients two years after the operation.

CONCLUSIONS

In primary hyperparathyroidism bilateral neck exploration yielded a high surgical success rate and provided long-term relief of symptoms. The morbidity of parathyroid surgery was influenced by a concomitant thyroid resection and a relationship was established between the number of intraoperatively identified parathyroid glands and the morbidity of the operation.

[Parathyroid gland carcinoma with postoperative encephalopathy]

We present a 78-year-old patient who suffered from symptomatic transitory psychotic syndrome after laparotomy. Persisting somnolence appeared with cardiopulmonary decompensation and gastrointestinal atony. Due to prolonged hypercalcemia primary hyperparathyreoidism was diagnosed. Resection of a large carcinoma of the parathyroids led to continuous clinical improvement.

[Evaluation of nephrologic "risk" in a newly diagnosed case of plasma cell dyscrasias from personal material (1994-2000)]

Among 149 patients with recently recognized plasma cell dyscrasia (PCD) in years 1994-2000 72 persons with serologically and nephrologically documented diagnostic profile were selected. In this group of pts we assessed dependence between degree of reduced glomerular filtration rate (GFR), evaluated by serum creatinine concentration and calculated with Barasckay's formula and hypercalcemia, hyperuricemia as well as type of monoclonal protein in urine.

RESULTS

We revealed statistically significant higher values of calcium (p = 0.005), uric acid (p = 0.000001) concentrations and higher occurrence of Bence-Jones proteinuria (mainly kappa) in 22 patients with serum creatinine > 1.5 mg/dl in comparison with 50 patients with serum creatinine < or = 1.5 mg/dl. Among 72 patients, GFR > 90 ml/min, calculated with Barasckay's formula, was stated only in 9 patients (12.5%). There was no difference in nephrotoxity between kappa and lambda light chains with reference to serum creatinine concentration and GFR. The group of 12 patients with light chain dyscrasia (LCD) had higher degree of nephrotoxicity in comparison with other forms of PCD. On the basis of our study we concluded that patients with clinical suspicion of PCD, especially those with LCD are referred to a special Protein Laboratory too late, it means at the time of significant nephrological risk in the form of low glomerular filtration rate, hypercalcemia and hyperuricemia.

[Familial benign hypercalcemia revealed by renal colic]

BACKGROUND

Diagnosis of familial benign hypercalcemia can be challenged by the association with a urinary lithiasis, which, in the presence of hypercalcemia, will most frequently lead to affirm primary hyperparathyroidism.

CASE REPORTS

We report the case of a 23 year-old patient who presented with a left ureteral stone composed of calcium oxalate. His serum total calcium value was 2.92 mmol/l. Serum PTH value was inappropriately in the normal range (32 ng/l, normal values 10 to 58 ng/l). Hypercalcemia persisted despite a subtotal parathyroidectomy and new investigation biochemical revealed familial benign hypercalcemia.

CONCLUSION

This diagnosis is usually made fortuitously, since most patients have few, if any, symptoms. A past familial history of hypercalcemia and several biochemical features (such as a reduced fractional excretion of calcium, mild hypermagnesemia, and a normal serum inorganic phosphorus level) are helpful dues to the diagnosis of familial benign hypercalcemia. In some cases, however, searching for an inactivating mutation of the extracellular calcium-sensing receptor gene is necessary to distinguish this autosomal dominant disease from primary hyperparathyroidism.

[Acute renal failure due to hypercalcemia and peripheral polyneuropathy--rare manifestations of sarcoidosis]

BACKGROUND

Sarcoidosis can involve many organs. Whereas lung and intrathoracal lymph nodes are most often effected, there are some rare manifestations as renal failure and neuropathy.

CASE REPORT

A 57-year-old male patient was referred to hospital with dyspnea on exertion, hypercalcemia and acute renal failure after holidays in Southern Europe. The diagnosis of sarcoidosis with the extraordinary manifestations of a nephropathia based on hypercalcemia and a sensitive polyneuropathy was made.

CONCLUSION

These findings suggest that an asymptomatic sarcoidosis can develop hypercalcemia with renal failure by increased ultraviolet exposure. Patients with sarcoidosis should avoid marked exposure to UV light.

Parathyroid-hormone-related-protein-producing thymic carcinoma presenting as a giant extrathoracic mass

A 53-year-old female with a 9-month history of chest pain presented with a giant anterior chest wall mass. Radiologic examination showed an anterior mediastinal tumor invading the chest wall. Serum calcium and parathyroid hormone-related protein (PTHrP) levels were extremely elevated. Biopsy specimens disclosed a squamous cell carcinoma with Hassall's corpuscle-like keratotic pearls, and an immunohistological study showed a positive staining with PTHrP. The tumor and serum PTHrP concentration markedly decreased following cisplatin-based chemotherapy and radiation. This is the first case of PTHrP producing a thymic carcinoma with the unusual presentation of a large extrathoracic mass.

Transient hypoparathyroidism following successful treatment of hypercalcaemia of malignancy in a dog

A 4-year-old, entire female, English Cocker Spaniel was presented for treatment of lymphosarcoma and secondary hypercalcaemia. After induction chemotherapy the dog became severely hypocalcaemic and showed signs of weakness, muscle fasciculation and facial pruritus. Hormone analysis confirmed inadequate production of parathyroid hormone. Although hypocalcaemia has been previously reported as a component of tumour lysis syndrome, it has not been associated with transient parathyroid hormone deficiency.

Vitamin D receptor gene polymorphism and calcium metabolism in sarcoidosis patients

BACKGROUND

Hypercalcemia has been recognized as an important complication of sarcoidosis, caused by overproduction of the active form of vitamin D, 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) at sites of granulomatous reactions. Polymorphism of the vitamin D receptor (VDR) gene has recently been shown to be related to bone mineral density, and also associated with hyperparathyroidism and risk of granulomatous disease. In light of the possible impact on hypercalcemia of sarcoidosis, an investigation of calcium metabolism and polymorphism of the VDR gene in sarcoidosis patients was carried out.

METHODS

Genotypes were determined using the polymerase chain reaction and restriction fragment length polymorphism. Maximum calcium, 1,25(OH)2D3, and intact PTH levels were also determined.

RESULTS

Depressed PTH levels were found in sarcoidosis patients, especially in those with the bb genotype, but there was no difference in 1,25(OH)2D3 levels among the VDR genotypes, and this polymorphism also had no association with onset of hypercalcemia.

CONCLUSION

From these results, we speculate that although the VDR gene polymorphism may affect the serum PTH level, it is not a risk factor for hypercalcemia in sarcoidosis.

Disorders of maternal calcium metabolism implicated by abnormal calcium metabolism in the neonate

Normal fetal and neonatal calcium homeostasis is dependent upon an adequate supply of calcium from maternal sources. Both maternal hypercalcemia and hypocalcemia can cause metabolic bone disease or disorders of calcium homeostasis in neonates. Maternal hypercalcemia can suppress fetal parathyroid function and cause neonatal hypocalcemia. Conversely, maternal hypocalcemia can stimulate fetal parathyroid tissue causing bone demineralization. We report two asymptomatic women, one with previously unrecognized hypoparathyroidism and the other with unrecognized familial benign hypercalcemia, who were diagnosed when their newborn infants presented with abnormalities of calcium metabolism. J.B. was born at 34 weeks' gestation with transient hyperbilirubinemia and thrombocytopenia. At 1 month of age he had severe bone demineralization, cortical irregularities, widening and cupping of the metaphyses, and lucent bands in the scapulae. The total serum calcium and phosphorus were normal with an ionized calcium of 5.4 mg/dL (4.6-5.4). His alkaline phosphatase, parathyroid hormone, and 1,25-dihydroxyvitamin D levels were all increased. P.B., mother of J.B., had no symptoms of hypocalcemia either prior to, or during this pregnancy. She had severe hypocalcemia and hyperphosphatemia, laboratory values typical of hypoparathyroidism. J.N. presented at 6 weeks of age with new onset of seizures and tetany secondary to severe hypocalcemia. The serum phosphorus, creatinine, alkaline phosphatase, and parathyroid hormone levels were normal. At 15 weeks of age his calcium was slightly elevated with a low fractional excretion of calcium. P.N., mother of J.N., had no symptoms of hypercalcemia either prior to, or during this pregnancy. Her serum calcium was 12.7 mg/dL and urine calcium was 66.5 mg/24 hr, with a low fractional excretion of calcium ranging from 0.0064 to 0.0073. P.N. has a brother who previously had parathyroid surgery. Both J.N. and P.N. meet the diagnostic criteria for familial benign hypercalcemia. These cases illustrate the important relationships between maternal serum calcium levels and neonatal calcium homeostasis. They emphasize the need to assess maternal calcium levels when infants are born with abnormal serum calcium levels or metabolic bone disease.

[Marginal primary hyperparathyroidism. Indication for treatment?]

Non familial primary hyperparathyroidism (pHPT) is often diagnosed accidentally by serum calcium screening. Som patients have marginally elevated calcium values, normal renal function, no renal stone disease and no clinical signs of bone disease. Bone densitometry reveals slightly reduced bone mineral content. Long time observation may show no progression. Observation is recommended due to the potentially stationary and symptomfree condition. Recent investigations have however shown that pHPT is associated with cardiac changes and elevated risk of cardiovascular death. Neuropsychiatric changes influencing level of function and quality of life have been demonstrated. There is therefore a substantial need for re-evaluation of the natural course of apparent asymptomatic pHPT and the effect of parathyroid surgery.

Hypercalcemia in granulomatous disorders: a clinical review

Hypercalcemia occurs in most granulomatous disorders. High serum calcium levels are seen in about 10% of patients with sarcoidosis; hypercalciuria is about three times more frequent. Tuberculosis, fungal granulomas, berylliosis, and lymphomas are other conditions that are associated with disorders of calcium metabolism. These abnormalities of calcium metabolism are due to dysregulated production of 1,25-(OH2)D3 (calcitriol) by activated macrophages trapped in pulmonary alveoli and granulomatous inflammation. Undetected hypercalcemia and hypercalciuria can cause nephrocalcinosis, renal stones, and renal failure. Corticosteroids cause prompt reversal of the metabolic defect. Chloroquine, hydroxychloroquine, and ketoconazole are the drugs that should be used if the patient fails to respond or develops dangerous side effects to corticosteroid therapy.

Hypercalcemia and T-cell lymphoma with acquired immunodeficiency syndrome: occurrence without human T-cell leukemia virus-I

We describe the case of a patient with acquired immunodeficiency syndrome (AIDS) who had a CD4 cell count of 60/microL, bilateral hilar adenopathy, and hypercalcemia. Transbronchial biopsy showed T-cell anaplastic large cell lymphoma. Serology was negative for human T-cell leukemia virus-I (HTLV-I). This appears to be the first case of T-cell anaplastic large cell lymphoma occurring in an AIDS patient with hypercalcemia who was seronegative for HTLV-I.