2. • 29/F
• 6.5 months pregnancy
• P/W
• Recurrent severe UTI with fever
• Gen body weakness
• Gen bony pains, off and on
• Mild abdominal pain
• Detected hypercalcemia in
preliminary investigations
• Confirmed PHPT biochemically on
extensive work up
3. Investigations
Serum Calcium
Total
Ionized
15.5 mg/dl (8-10)
1.92 mmol/L (1.15-1.29)
S iPTH 1154 pg/ml (15-68)
Serum iPhosphorous
S Alkaline Phosphatase 322 U/L (30-120)
S Creatinin 1.2 mg/dl
S 25 OH Vitamin D Insufficient
LFT WNL
Na/ K / Cl 133/ 4.2/ 105
TSH 0.64
Hb 9
TLC 17,600
Urine 8-10 pus cell/hpf
4. Localization
• USG Neck
• 2.6x0.9x1.6 cm predominantly hypoechoic
SOL postero-lateral to the inferior pole of right
lobe of thyroid. Thyroid- normal
• Sestamibi scan- not done in view of pregnancy
5. Management
• Intravenous hydration -300-500 ml/hr
• S/c Calcitonin
• Iv Bisphosphonates
• Susten p/v
• Iv betamethasone
• Iv antibiotics and supportives
9. PREFERRED APPROACH
• Mild hypercalcemia — Asymptomatic or mildly
symptomatic hypercalcemia (Ca<12mg/dL
[3 mmol/L]) do not require immediate Tt
• They should avoid
– Thiazide diuretics
– Lithium
– Volume depletion
– Prolonged bed rest or inactivity
– High calcium diet (>1000 mg/day).
• They should have
– Adequate hydration
– Additional therapy depends upon the cause
13. SEVERE HYPERCALCEMIA
• Concurrent administration of zoledronic acid (ZA;
4 mg IV over 15 min) or pamidronate (60 to 90
mg over 2 hrs), preferably ZA
• Administration of calcitonin + saline should result
in substantial reduction in S.Ca within 12-48 hrs.
• Bisphosphonate will be effective by 2nd to 4th
day, failed to reverse hypercalcemia, mental
status changes, and hypophosphatemia due to
primary hyperparathyroidism
14. SEVERE HYPERCALCEMIA
• Hypercalcemia due to calcitriol, usually lasts
only one to two days because of the relatively
short biologic half-life
• Hypercalcemia caused by vit D lasts longer, so
that more aggressive therapy such as
glucocorticoids & ZA or pamidronate
• Hypercalcemia is not treated in FHH because
it is mild & produces few symptoms
15. SEVERE HYPERCALCEMIA
• More aggressive measures are necessary in
the rare patient with very severe,
symptomatic hypercalcemia
• Hemodialysis should be considered, in
addition to the above treatments, in pts who
have serum calcium concentrations in the
range of 18 to 20 mg/dL (4.5 to 5 mmol/L) &
neurologic symptoms but a stable circulation,
or in those with severe hypercalcemia
complicated by renal failure