Hypercalcemia in a patient with polycythemia vera.

Images in Clinical Medicine www.cmj.ac.kr Hypercalcemia in a Patient with Polycythemia Vera Eun Hui Bae, Hyun Soo Kim1, Min Jee Kim, Yong Un Kang, Yeong Hui Kim2, Chang Seong Kim, Joon Seok Choi, Seong Kwon Ma and Soo Wan Kim* Department of Internal Medicine, Chonnam National University Medical School, Gwangju, 1Department of Internal Medicine, Hankook Hospital, Mokpo, 2Department of Pathology, Chonnam National University Medical School, Gwangju, Korea A 59-year-old female with diabetes mellitus presented with hypercalcemia and polycythemia. Her serum calcium and intact parathyroid hormone (iPTH) levels were increased, and Tc-99m sesta-MIBI scanning showed hot uptake in the lower portion of the left thyroid lobe. After parathyroidectomy, her calcium, iPTH, and polycythemia were normalized. In conclusion, the differential diagnosis of polycythemia and hypercalcemia should also include the possibility of a parathyroid tumor in addition to other neoplasms. Key Words: Hypercalcemia; Polycythemia vera; Parathyroid tumor This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Article History: received 15 June, 2012 revised 26 June, 2012 accepted 28 June, 2012 Corresponding Author: Soo Wan Kim Department of Internal Medicine, Chonnam National University Medical School, 42, Jebongro, Gwangju 501-757, Korea TEL: +82-62-220-6272 FAX: +82-62-225-8578 E-mail: to 221 pg/ml (normal range, 10-65) and her intact parathyroid hormone-related protein (PTHrP) was below 1.1 pmol/L (normal range, ＜1.1). The concentration of 1,25-dihydroxyvitamin D3 was 63.54 pg/ml (normal range, 18.7-47.7), calcitonin was below 1.0 pg/ml (normal range, 1.0-4.8), and erythropoietin was 4.3 mIU/ml (normal range, 3.22-31.90). The 24-h urinary concentration of calcium was 820 mg/day and urine output was 3,150 ml. She did not have splenomegaly as shown by abdominal ultrasonography. She underwent neck ultrasonography and Tc-99m sesta-MIBI scanning (Fig. 1). WHAT IS THE CAUSE OF HER HYPERCALCEMIA AND ERYTHROCYTOSIS? A 59-year-old female with diabetes mellitus presented with hypercalcemia. Her blood counts were as follows: hemoglobin, 18.2 g/dl; hematocrit, 55.1%; platelets, 361×109/L; and leukocytes, 6.82×109/L. Serum chemistry values were as follows: creatinine, 0.9 mg/dl (normal range, 0.5-1.3); albumin, 5.4 g/dl (4.0-5.2); LDH, 359 IU/L (180-460); ALP, 62 IU/L (104-338); calcium, 12.6 mg/dl (8.6-10.4); and phosphate, 1.9 mg/dl (2.5-4.4). Her serum level of intact parathyroid hormone (iPTH) was increased FIG. 1. Tc-99m sesta-MIBI scanning. http://dx.doi.org/10.4068/cmj.2012.48.2.128 Ⓒ Chonnam Medical Journal, 2012 128 Chonnam Med J 2012;48:128-129 Eun Hui Bae, et al TABLE 1. Serial laboratory data Hemoglobin (g/dl) PTH (pg/dl) Total calcium (mg/dl) FIG. 2. Parathyroid adenoma. The tumor is hypercellular, homogeneous, and well vascularized. ×200. THE DIAGNOSIS: POLYCYTHEMIA VERA ASSOCIATED WITH PARATHYROID ADENOMA The laboratory data and imaging tests showed hypercalcemia associated with hyperparathyroidism. The patient underwent an operation, and intraoperative exploration of the neck and mediastinum revealed a nodular lesion on the left lobe at the location noted by the parathyroid ultrasonography and scintigraphy. The histopathologic examination of this nodule showed a parathyroid adenoma (Fig. 2). Postoperatively, the patient’s PTH dropped to 34 pg/ml and her calcium level was 9.8 mg/dl at 1 month after the operation. Moreover, her hemoglobin and hematocrit dropped dramatically to 15.5 g/dl and 46.7%, respectively (Table 1). Hypercalcemia in myeloproliferative disorders such as polycythemia vera is usually thought to be related to malig1 nancy, especially renal cell carcinoma. Other secondary causes of increased red cell mass are various and include chronic lung disease, smoking, renal artery stenosis, hep2 atocellular carcinoma, and hydronephrosis. However, an Before operation After operation 18.2 221 12.6 15.5 34 9.8 association between hyperparathyroidism and polycythemia vera has rarely been reported. In a previous co3 hort-based study, the co-incidence of primary hyperparathyroidism and polycythemia vera was significantly increased, and it was unlikely that this was explained completely by bias or chance. Rather, biologically plausible explanations were identified. The parathyroid tumor may have produced or induced production of a growth factor that can stimulate pancytosis. Moreover, a previous report suggested that the calcium-PTH axis is important for the acti4 vation of erythropoiesis, but the cause-effect relationship between PTH and myeloproliferative disorders is not yet completely understood. This case demonstrates an association of polycythemia vera and parathyroid adenoma. In conclusion, the differential diagnosis of polycythemia and hypercalcemia should also include the possibility of a parathyroid tumor in addition to other neoplasms. REFERENCES 1. Skrabanek P, McPartlin J, Powell D. Tumor hypercalcemia and "ectopic hyperparathyroidism". Medicine (Baltimore) 1980;59: 262-82. 2. Landolfi R, Nicolazzi MA, Porfidia A, Di Gennaro L. Polycythemia vera. Intern Emerg Med 2010;5:375-84. 3. Pizzolito S, Barbone F, Rizzi C, Scott AC, Piemonte M, Beltrami CA. Parathyroid adenomas and malignant neoplasms: coincidence or etiological association? Adv Clin Path 1997;1:275-80. 4. Tiryakioglu O, Kadioglu P, Ongören S, Açbay O, Ferhanoglu B, Gündoglu S, et al. 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