Vitamin A And Hydrochlorothiazide Causing Severe Hypercalcemia In A Patient With Primary Hyperparathyroidism.

Presentation Number: SAT-479-LB
Date of Presentation: March 17, 2018, 2018

Ron Thomas Varghese, MBBS1, Raman K. Desikan, MBBS, MD1, Anandaraj Subramaniam, MBBS1, Ganesh Nair, MBBS, MD2.
1White River Medical Center, BATESVILLE, AR, USA, 2Little Rock Diagnostic Clinic, Little Rock, AR, USA.

Abstract

Introduction:Vitamin supplementation is commonly used,most of these supplements are available over the counter. We present a case of severe hypercalcemia, exacerbated by Vitamin A(VitA) supplementation& Hydrochlorothiazide(HCTZ),in a patient with primary hyperparathyroidism(HPT).Case Presentation:68 year old white female presented to ED complaining of nausea, vomiting & altered mental status.She was being treated for diverticulitis with Ciprofloxacin & Metronidazole.Physical Examination revealed severe dehydration. Labs revealed calcium 15.8mg/dl(8.4-10.2), albumin 4.1g/dL(3.8 - 4.8), PTH 62pg/ML(14- 64).She was treated with iv hydration with normal saline resulting in improvement in serum Calcium.Prior to this hospitalization she was on Calcium,VitA(11,000 IU daily),Vitamin D(VitD) supplementation& HCTZ.These were stopped during hospitalization.Endocrinology evaluation showed serum calcium 11.1mg/dl,albumin 4.4g/dL,Phosphorus 3.0 mg/dl(2.5 - 4.8)& PTH 98.9pg/ml.25-OH Vit D;1,25-OH Vit D& PTH-RP were normal.Serum immunofixation electrophoresis showed poorly defined area of monoclonal protein.She underwent Oncology evaluation to rule out multiple myeloma.Urine kappa light chains was increased, as was urine free Kappa/Lambda ratio,but no monoclonal spike detected in urine electrophoresis.On quantitative immunoglobulin evaluation IgG&IgA were normal,IgM minimally elevated,immunofixation revealed IgG Lambda monoclonal protein.She thus had MGUS but no myeloma, thus myeloma wasnt contributing to hypercalcemia.Her normal VitD and ACE ruled out Lymphoma or sarcoidosis contributing for hypercalcemia.Further labs indicated, elevated Calcium 10.9mg/dl, PTH 48.6(inappropriately normal), Phosphorus 3.2mg/dl, albumin 3.9g/dl, creatinine 0.8mg/dl. 24 hour urine Calcium 146 mg(35 - 250), creatinine 1.27 g(0.8 - 2.8), creatinine clearance 134.5 ml/min, with urine volume 2700 ml.This was performed few weeks after stopping HCTZ.The diagnosis of Primary HPT was confirmed.Discussion: Primary hyperparathyroidism is a fairly common condition(7/1000 adults)however severe hypercalcemia secondary to primary HPT is uncommon.Hypercalcemia of primary HPT can be exacerbated by coexisting conditions which cause increase in bone turn over.Hypervitaminosis A is a rare cause of hypercalcemia.Reports suggest very high doses of VitA required to cause hypercalcemia.The case suggests,in a setting of primary hyperparathyroidism,and HCTZ therapy,even smaller doses of VitA can lead to severe hypercalcemia.Also the patient was on calcium& VitD replacement.This teaches that commonly used antihypertensive & vitamin supplements may sometimes lead to life threatening situations given the right setting.We should try to improve awareness in the population that vitamins have biological effects& their injudicious use could lead to dangerous situations.*Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Disclosures

 R.T. Varghese: None. R.K. Desikan: None. A. Subramaniam: None. G. Nair: None.