Life-threatening Hypercalcemia Research Articles

Parathyroid carcinoma with pancreatitis causing hypercalcaemic emergency treated with extracorporeal membrane oxygenation-assisted parathyroid resection.

Emergencies due to malignancies usually have a severe clinical course and require urgent treatment. These scenarios are dubbed 'oncologic emergencies'. Parathyroid tumours often cause hypercalcaemia but not oncologic emergencies. We present a case of parathyroid carcinoma with severe hypercalcaemia and pancreatitis, resolved by surgical resection of the tumour assisted by extracorporeal membrane oxygenation (ECMO). A 66-year-old woman presented to our hospital because of haematuria. Laboratory findings were as follows: white blood cell count: 30 000, C-reactive protein: 17.7, calcium: 21.9, creatine kinase: 316, creatine kinase-myoglobin binding: 20, troponin I: 1415.8, amylase: 1046, lipase: 499, blood urea nitrogen: 57, and creatinine: 2.42. ECG was unremarkable. CT revealed a 4-cm low-density irregular tumour in the left lobe of the thyroid gland and severe pancreatitis. We diagnosed hypercalcaemia and pancreatitis due to parathyroid carcinoma. Volume expansion with isotonic saline was started immediately. Calcitonin, followed by denosumab, calcimimetic agents, and continuous hemodiafiltration were administered. The patient's general condition worsened due to uncontrolled hypercalcaemia. Urgent tumour resection was planned, assisted with ECMO for cardiopulmonary support and surgical field venous pressure reduction. Tumour histology was suggestive of parathyroid carcinoma. Hypercalcaemia and the patient's general condition improved gradually postoperatively. Hypercalcaemia is one of the oncologic emergency symptoms, commonly occurring because of lytic bone metastasis. However, reports about parathyroid carcinoma-causing life-threatening hypercalcaemia and pancreatitis are scarce; the fatality of this condition is estimated to be 30-70%. We report a case of survival of hypercalcaemia of malignancy. Parathyroid carcinoma is relatively rare and sometimes causes emergent conditions such as hypercalcaemia and severe pancreatitis. General therapy for hypercalcaemia including aggressive saline dehydration, administration of furosemide, calcitonin, zoledronic acid, and evocalcet, and dialysis is sometimes ineffective for parathyroid carcinoma. Therefore, careful planning of therapy in case of exacerbation is important. During an emergency, rapid surgical treatment despite high calcium level is the best potential therapeutic strategy.

Treatment of Parathyroid Cancer: Current Status and Near-Term Prospects

Parathyroid cancer (PС) is a rare malignant neoplasm of the endocrine system, characterized by a severe course due to the development of life-threatening hypercalcemia. Despite a relatively high survival rate, recurrence occurs about half the time. The aggressive course of PС is associated with both local spread of the process and distant metastasis. With the exception of isolated cases, cytotoxic chemo- and radiotherapy are inefficacious, and treatment protocols have not been developed. Therefore the only effective way is the surgical removal of secondary lesions, which is not always technically feasible and is associated with a high risk of postoperative complications. The literature describes individual cases of successful use of targeted therapy, as well as immunotherapy in the form of therapeutic vaccination to induce an immune response against parathyroid hormone (PTH) and block immune checkpoint. A promising direction of study is the tumor immunoenvironment, which has both diagnostic and prognostic value in relation to the likelihood of the spread of the tumor process. In this review, we describe the main directions in the treatment of PC, including disseminated forms, the possibilities of immunotherapy will be considered in details.

Nephrocalcinosis in children who received high-dose vitamin D

Vitamin D supplements are readily available as over-the-counter preparations. However, although rare, cases of vitamin D overdose still occur and are associated with nephrocalcinosis and life-threatening hypercalcemia. Errors in manufacturing of nutritional supplements may be a cause of vitamin D intoxication in children. This study aimed to identify factors associated with vitamin D overdose-related nephrocalcinosis in children due to manufacturing errors in supplements. This retrospective study reviewed medical charts of pediatric patients with non-registered supplement-related vitamin D overdose at a tertiary referral hospital between 2006 and 2011. Clinical and laboratory characteristics of patients with or without nephrocalcinosis were evaluated. Receiver operating characteristics curve and area under the receiver operating characteristics curve were used to determine the most predictive value of each characteristic. A total of 44 patients (males: 29; age: 7-62months) were included. Age ≤ 16.5months, body weight ≤ 10.25kg, body height ≤ 78.5cm, body surface area (BSA) ≤ 0.475 m2, 25-hydroxyvitamin D3 ≥ 143ng/mL, and calcium ≥ 10.65mg/dL were predictive of developing nephrocalcinosis with a sensitivity and specificity of > 60%. Univariant analysis revealed that BSA was the most significant anthropometric prognostic factor (odds ratio: 12.09; 95% confidence interval: 2.61-55.72; P = 0.001). Children with smaller BSAs were more vulnerable to high-dose vitamin D3-related nephrocalcinosis. Physicians and parents should be aware of the potential adverse effects of vitamin D overdose in children. A higher resolution version of the Graphical abstract is available as Supplementary information.

Anti-TNF Induced Sarcoidosis-Like Disease in Rheumatoid Arthritis Patients: Review Cases from the RA UCLouvain Brussels Cohort.

IntroductionDrug-induced sarcoidosis-like disease is a rare side effect of anti-tumor necrosis factor (anti-TNF) agents in rheumatoid arthritis (RA) patients. The most commonly involved organs in such condition are the lungs, skin, and lymph nodes. The aim of this study is to report the number of cases and the clinical manifestations of sarcoidosis induced by anti-TNF in our RA UCLouvain Brussels cohort.MethodsAll case records of RA patients ever treated with a TNF inhibitor and presenting anti-TNF induced sarcoidosis in our rheumatology centers from 2000 to 2021 were retrospectively reviewed.ResultsOur RA UCLouvain Brussels cohort includes 2492 patients. Among them, 697 patients have been or are exposed to a TNF inhibitor. Only four patients with sarcoidosis induced by anti-TNF were identified and reviewed. Patient 1 was classified as incomplete Heerfordt syndrome. Patient 2 was a case of sarcoid-like granulomatosis manifesting as life-threatening hypercalcemia, acute kidney injury and atypical parenchymal pneumopathy. Patients 3 and 4 developed pulmonary sarcoidosis with hilar adenopathies. The TNF inhibitor was etanercept for the first three patients and infliximab for the last one. The time occurrence of sarcoidosis was highly variable after anti-TNF exposure. All patients recovered after glucocorticoid treatment and the discontinuation of the anti-TNF agent.ConclusionsThis case highlights this rare paradoxical side effect and the variability of the clinical presentation. Further studies should analyze the immunopathology of such conditions.

Roles of calcium signaling in cancer metastasis to bone.

Bone metastasis is a frequent complication for cancers and an important reason for the mortality in cancer patients. After surviving in bone, cancer cells can cause severe pain, life-threatening hypercalcemia, pathologic fractures, spinal cord compression, and even death. However, the underlying mechanisms of bone metastasis were not clear. The role of calcium (Ca2+) in cancer cell proliferation, migration, and invasion has been well established. Interestingly, emerging evidence indicates that Ca2+ signaling played a key role in bone metastasis, for it not only promotes cancer progression but also mediates osteoclasts and osteoblasts differentiation. Therefore, Ca2+ signaling has emerged as a novel therapeutical target for cancer bone metastasis treatments. Here, the role of Ca2+ channels and Ca2+-binding proteins including calmodulin and Ca2+-sensing receptor in bone metastasis, and the perspective of anti-cancer bone metastasis therapeutics via targeting the Ca2+ signaling pathway are summarized.

Percutaneous vertebroplasty in metastatic vertebral fracture: A retrospective cross-sectional study

Introduction: Metastatic vertebral fractures (VF) commonly cause severe disabling pain in cancer patients. VFs are common among elderly patients and account for approximately 1.5 million per year in the general population. Objective: Bone metastasis, which is a second major cause of pathologic fracture, may lead to severe intolerable pain, life-threatening hypercalcemia, spinal cord compression, and immobility. The purpose of this study was to evaluate pain relief and improvement in quality of life (QOL) in patients with metastatic VF undergoing percutaneous vertebroplasty (PVP). Methods: Ten cancer patients having metastatic VF underwent PVP from July 2018 to August 2020. All demographic data, procedures, improvement in pain, and analgesic requirements of patients were taken from a computer data system and telephonic follow-up. Results: Majority of patients were suffering from carcinoma lung followed by carcinoma pancreas. The mean ± standard deviation of Visual Analog Scale preoperatively was 8.8 ± 1.35, reduced to 2.14 ± 2.11 at 6 months postoperatively, suggesting significant pain reduction. Eight patients had reduction in analgesic requirements and two did not require any analgesics postoperatively. During the entire follow-up, there was no delayed complication. Conclusion: PVP is an effective, safe, and minimally invasive procedure for treating painful metastatic vertebral compression fracture refractory to conservative treatments. It provides a marked reduction of pain, maintains mechanical stability of the vertebrae, and improves QOL.

Successful Outpatient Management of Severe Ionized Hypercalcemia Secondary to Cholecalciferol Ingestion in a Puppy

ABSTRACT A 4 mo old female intact boxer was presented because of polyuria, lethargy, and vomiting after ingestion of cholecalciferol rodenticide roughly 3 days prior. Blood work revealed an ionized hypercalcemia 2.23 mmol/L (reference range 1.04–1.33 mmol/L) on presentation. Because of financial limitations, the patient was unable to be hospitalized for standard of care. She was treated with a pamidronate infusion and discharged with medical management to include oral prednisone, furosemide, and subcutaneous fluids. The dog’s signs, body weight, and biochemical parameters were serially monitored over 3 wk as the ionized hypercalcemia resolved. To the authors’ knowledge, this is the first published report documenting a successful outpatient medical protocol for potentially life-threatening hypercalcemia secondary to cholecalciferol toxicosis in a puppy.

EP124 - Neonatal severe hyperparathyroidism caused by homozygous mutation in CASR gene: A rare cause of life-threatening hypercalcemia

eP124 - Neonatal severe hyperparathyroidism caused by homozygous mutation in CASR gene: A rare cause of life-threatening hypercalcemia

RISK OF HYPERCALCEMIA IN ELDERLY PATIENTS WITH HYPERVITAMINOSIS D AND INTOXICATION.

We aimed to determine the risk of hypercalcemia in a geriatric population with very high dose levels of 25-hydroxy-vitamin D (25(OH)D). This study was designed as a retrospective, cross-sectional two-center study for examining the elderly patients with very high 25(OH)D levels (>88ng/mL) between January 2014 and December 2019. After recruitment, subgroup analyses of the patients were performed based on their calcium and vitamin D levels. A total of 81.101 elderly patients, who had been evaluated for their vitamin D levels, were screened. Of the 458 (0.6%) elderly patients with 25(OH)D>88 ng/mL according to our criteria, 217 patients with complete data were accepted into our study. The median 25(OH)D level was 103.7ng/mL (min-max:88.2-275.9). Most of the elderly patients (86.6%) with very high 25(OH)D levels were normocalcemic. When patients with hypercalcemia were compared with normocalcemic group, no difference was observed in the levels of 25(OH)D, intact parathormone (iPTH), phosphorus, alkaline phosphatase (ALP), and their age. However, the PTH suppression rate was significantly higher in hypercalcemic group (p=0.005). The elderly patients with very high 25(OH)D levels would appear to be mostly normocalcemic whereas life-threatening hypercalcemia would also occur. Treatment and follow-up planning should be done according to the clinical guideline recommendations.

Severe hypercalcaemia secondary to vitamin D intoxication in a 2-year-old boy – a case report

The aim of the study was to draw attention to the danger of vitamin D overdose. The beneficial effects of vitamin D are described in both scientific literature and popular science journals. On the other hand, papers on the symptoms of excess intake of vitamin D are scarce. Since vitamin D preparations are easily accessible, they are widely used in both adults and children without any medical supervision. We present a case of a 2-year-old boy with life-threatening hypercalcaemia due to excess vitamin D intake. The boy required prolonged hospital stay, intensive therapy to reduce blood calcium, complex pharmacotherapy and hemofiltration. Abdominal ultrasonography performed after therapy completion showed enlargement of both kidneys and persistent hyperechogenicity of renal cortex. Expert recommendations specify the route of administration and the dose of vitamin D. In the era of the Internet, however, opinions suggesting doses that are inconsistent with recommendations may be found. Such management may have serious health consequences and even be life-threatening in some cases.

Dermatomyositis Presenting as Life-threatening Hypercalcemia

Dermatomyositis is a rare disease characterized by classic skin lesions and muscle weakness. In rare cases, life-threatening hypercalcemia may develop caused by regression of dystrophic calcifications. Here we report a 36-year-old man who presented with progressive proximal weakness, difficulty in ambulation, and weight loss. He had the V-sign, Gottron’s papules, and hard, chalky nodules on both antecubital, thigh, and hip areas. Laboratory examinations revealed hypercalcemia (3.47 mmol/L) and shortened QT interval. Workup for malignancy and tuberculosis yielded negative results. Biopsy of the antecubital areas revealed calcinosis cutis. Serum calcium levels gradually normalized with hydration and steroids. Our case illustrated that a high index of suspicion for dermatomyositis is warranted for early diagnosis and ascertaining the etiology of hypercalcemia is vital in the management of this life-threatening complication. While hypercalcemia from dermatomyositis may respond to steroids, to date, individualization of treatment remains the standard of care. (J Rheum Dis 2020;27:285-289)

O09 Isolated muscular sarcoidosis revealed by calcitriol-mediated hypercalcaemia and fluorodeoxyglucose positron emission tomography

Case report - IntroductionSarcoidosis, a multisystem disorder of unknown aetiology, commonly presents with bilateral hilar adenopathy, pulmonary infiltrates, skin and/or eye lesions. Musculoskeletal and neuromuscular manifestations occur less commonly.Calcitriol-mediated hypercalcaemia is a known complication of sarcoidosis. Severe hypercalcaemia, however, is detected in ˂5% of patients and pseudo-malignant hypercalcaemia (>3.5 mmol/L) is very unusual.There are limited reports of isolated granulomatous myositis causing hypercalcaemia. Our patient uniquely presented with symptoms of hypercalcaemia and PET-scan incidentally revealed sarcoid-like myositis. This case reports an unusual presentation of life-threatening hypercalcaemia revealing sarcoid myositis that rheumatologists and physicians should be aware of.Case report - Case descriptionThe patient, a 69-year old Caucasian female, was referred to Rheumatology after a PET-scan identified features of sarcoid myositis. She was initially admitted due to hypercalcaemia and 2 months of tiredness, lethargy, generalised weakness, and nausea. She had difficulty in climbing stairs but was independently mobile with no difficulty standing from sitting. History included biopsy-proven cutaneous lupus (on Hydroxychloroquine, which she stopped weeks prior to admission), chronic interstitial cystitis and CKD stage 3A without proteinuria.Clinical examination was unremarkable. Bloods showed hypercalcaemia (3.62 mmol/L) with inappropriately normal PTH (1.8 qmol/L) and a raised ACE (72 U/L). PET-scan showed symmetric, diffuse, and heterogeneous muscular activity within the posterior thighs, anterior to the hips and psoas muscles, reported as possible sarcoid-like myositis. PET-scan findings were discussed with nuclear medicine team and deemed non-specific. Remaining results included phosphate 1.28, ALP 78, vitamin D3 64, urea 8.6, creatinine 97, e-GFR 49, ESR 10 and CK 30. Normal CXR, CT head and MIBI NM parathyroid scan. CT thorax, abdomen and pelvis showed bladder calcification. Calcium level and symptoms resolved with IV fluid, IV pamidronate and zoledronic acid. She was discharged with follow up arranged.Follow-up bloods revealed high 1,25 vitamin D of 259 (43-144pmol/L) raising the possibility of calcitriol-mediated hypercalcaemia from granulomatous myositis. EMG showed borderline myopathic results. Calcium levels and symptoms remained stable, so no treatment was initiated until 6 months following initial presentation, when she was readmitted with severe hypercalcaemia, similar symptomatology, and normal examination. MRI thighs showed changes consistent with myositis and muscle biopsy revealed granulomatous inflammation consistent with sarcoid. Myositis autoantibodies (anti Ro-52) came back positive. After 10 months of multiple investigations and monitoring, a diagnosis of sarcoid myositis has been made and patient initiated on a Prednisolone tapering regimen; her response is yet to be assessed. Case report - DiscussionIn patients with granulomatous disease, such as sarcoidosis, hypercalcaemia occurs because of ectopic 25(OH)D-1-hydroxylase expression in macrophages and formation of excessive amounts of 1,25(OH)2D. In a review of 101 adult cases of calcitriol-mediated hypercalcaemia, 48% were eventually diagnosed with sarcoidosis.Sarcoid myositis, as described by Aubart et all, has four patterns: nodular; smouldering phenotype; acute, subacute, or progressive myopathic; and combined myopathic/neurogenic type. In all patterns, sarcoidosis was multi-visceral with a median of 3 extra muscular organs involved (mostly lungs, lymph nodes, eyes, and skin). Our patient, however, did not fit into one of these patterns given her single-organ involvement which is clearly challenging. Furthermore, rather uniquely, our patient had no respiratory symptoms and chest imaging did not reveal hilar lymphadenopathy. It was the PET-scan, performed as part of malignancy screen for resistant hypercalcaemia, which highlighted the diagnosis. However, due to lack of objective weakness on examination and normal CK the significance of this incidental nonspecific finding was deemed low.A literature review has highlighted 12 similar cases where PET-scan, performed as malignancy screening for hypercalcaemia, incidentally, revealed intense, diffuse, and isolated muscular FDG uptake consistent with granulomatous myositis. CK was normal in all cases and no patients displayed the usual thoracic features of sarcoidosis. All patients were treated with high-dose steroids and achieved rapid, complete, and sustained remission.Case report - Key learning pointsSarcoidosis should be considered in patients presenting with symptomatic hypercalcaemia with no apparent causes and negative routine workup. The absence of proximal weakness or elevated muscle enzymes do not preclude the diagnosis of granulomatous myositis.Severe hypercalcaemia revealing a diffuse granulomatous disorder limited to muscles might be life threatening and following literature review appears highly steroid-sensitive.We describe a rare case where PET-scan incidentally revealed sarcoid-like myositis features which were subsequently demonstrated by muscle biopsy. Rheumatologists and physicians should be aware of this potential cause of markedly elevated calcium, even with normal CK and CXR and no prior sarcoidosis diagnosis. Earlier recognition of this disease phenotype can avoid unnecessary investigations, diagnosis delay and added stress to patients.

От стремления изменить внешность до паратгормон-независимой гиперкальциемии: осложнения косметологических инъекций

Plastic surgery and cosmetic procedures, the number of which has been increasing exponentially in recent years, as well as related complications, have added to the list of parathyroid hormone-independent hypercalcemia causes. So, one of the delayed complications of silicone, paraffin oil, and polymethymethacrylate injections is hypercalcemia. Severe and sometimes life-threatening hypercalcemia can develop several years after cosmetic procedures. It is the result of granulomatous inflammation and most often extrarenal calcitriol synthesis by activated macrophages. Therefore, cosmetic post-injection granuloma should be considered as a cause of hypercalcemia, especially in middle-aged women who do not have parathyroid-mediated hypercalcemia or hypercalcemia in the outcome of paraneoplastic processes.

Control of Refractory Hypercalcemia with Denosumab in a Case of Metastatic Parathyroid Carcinoma

Parathyroid carcinoma is a rare cause of hyperparathyroidism and leads to severe hypercalcemia. The etiology is not fully known. Parathyroid cancer should be considered in the differential diagnosis, if serum calcium and parathyroid hormone levels increase, and parathyroid gland is palpable. Severe hypercalcemia is the most common cause of death in patients diagnosed with parathyroid carcinoma. Fluid replacement, diuretic therapy, bisphosphonates, and calcimimetic agents are the main treatment steps in the control of life-threatening hypercalcemia. Surgery is the primary treatment option, while denosumab is a treatment option for refractory hypercalcemia caused by parathyroid carcinoma, or for patients who are not eligible for surgery. There are few case reports in literature about denosumab treatment for parathyroid carcinoma. Herein, we report a case of a patient who presented with the complaint of leg pain and was diagnosed with parathyroid carcinoma. The elevated calcium level of the patient was controlled with denosumab. Key Words: Parathyroid carcinoma, Denosumab, Hypercalcemia, Hyperparathyroidism.

Neonatal hypercalcemia associated with extensive subcutaneous fat necrosis: a case report

Subcutaneous fat necrosis (SCFN) of the newborn is rare self-limited fat tissue inflammation that usually occurs in term or post-term newborns exposed to perinatal stress factors, such as perinatal asphyxia, meconium aspiration, neonatal sepsis, and therapeutic hypothermia. SCFN usually appears in the first few weeks of life and has a benign course with spontaneous resolution. Monitoring for complications, in particular the potentially life-threatening hypercalcemia, is crucial. In this report, we describe a male infant with extensive SCFN and neonatal hypercalcemia that went through a prolonged course.

Ethical framework for head and neck endocrine surgery in the COVID-19 pandemic.

Ethical framework for head and neck endocrine surgery in the COVID-19 pandemic.

Хондрокальциноз как ранний признак первичного гиперпаратиреоза

Objective: To deeply analyse a case of a patient with calcium pyrophosphate crystal storage disease, where chondrocalcinosis (CC) preceded primary hyperparathyroidism (PHPT). Key Points. The association of CC and hyperparathyroidism is well-known; and CC is recognised as one of the late signs of hyperparathyroidism. We describe a 67-year old patient with PHPT, presenting for a long time only with X-ray CC and chronic arthritis, associated with calcium pyrophosphate deposits. At the same time, he did not have any electrolyte imbalances, had normal serum calcium and parathyroid hormone levels; PHPT was diagnosed after 10 years of follow-up when the patient developed life-threatening hypercalcemia. It can be assumed that, unlike other musculoskeletal signs, CC can be one of the earliest symptoms of hyperparathyroidism. Treating CC as a late sign of hyperparathyroidism is likely to be associated with challenges of early diagnosis (asymptomatic in some patients, low sensitivity of X-ray diagnostics). In order to assess the diagnostic value of CC in hyperparathyroidism, including patients with normal calcium levels, specific tests are essential. Conclusion. Target examination for CC using highly-sensitive methods in patients with minor calcium metabolism disturbances, high/normal parathyroid hormone level or slightly increased parathyroid hormone level and normal calcium can improve the detection frequency of both CC and PHPT and follow-up of such patients. Early PHPT diagnosis (prior to clinical presentation) can help in preventing severe, life-threatening complications. Keywords: chondrocalcinosis, primary hyperparathyroidism, parathyroid hormone, calcium pyrophosphate crystal storage disease, hypercalcemia.

Neonatal Severe Primary Hyperparathyroidism: A Series of Four Cases and their Long-term Management in India.

Context:Neonatal severe primary hyperparathyroidism (NSPHPT) is an extremely rare autosomal recessive disorder, requiring a high index of suspicion. Infants affected with this disorder present with severe life-threatening hypercalcemia early in life, requiring adequate preoperative medical management followed by surgery.Aims:We report four newborns with NSPHPT who were managed over 10 years.Subjects and Methods:Demography, clinical presentation, treatment, and follow-up data were retrospectively studied with descriptive analysis to highlight the utility of long-term medical management, surgery, and genetic testing reported in the literature.Statistical Analysis Used:Descriptive Analysis.Results:We had three males and one female infant with a mean age of diagnosis at 28.7 days, calcium 29.2+/-2.8 mg/dL, and parathormone (PTH) 1963+/-270.4 pg/mL. All four infants presented with failure to thrive, hypotonia, and respiratory distress. All infants were treated medically followed by total parathyroidectomy plus transcervical thymectomy, with an additional hemithyroidectomy in one of them. Imaging was negative in all four cases. Three babies became hypocalcemic while the fourth infant had a drop in PTH and is on the tab. cinacalcet 30 mg/day. CaSR mutation was positive in three infants.Conclusions:Diagnosing NSPHPT needs expert clinical acumen. It requires emergency medical management to control calcium levels. The crisis may present later, necessitating parathyroidectomy in these cases once the child is fit for surgery. Surgery offers a cure for this unusual lethal hypercalcemia while the role of cinacalcet needs a special mention. Sound knowledge in endocrinology with parathyroid embryology and morphology is of paramount importance. Our case series might add a few insights into managing this unusual genetic disorder.

Parathyroid surgery during the COVID-19 pandemic: Time to think about the “New Normal”

International recommendations for parathyroid surgery during the initial response to COVID-19 The Society of Surgical Oncology issued a statement with some recommendations for endocrine surgery on March 30, 2020 (). This statement endorsed the opinion of the American Association of Endocrine Surgeons for parathyroid surgery. Parathyroidectomy was recommended only for life-threatening hypercalcemia that could not be controlled by medical treatment (). […] Parathyroid surgery during the COVID-19 pandemic: Time to think about the “New Normal”

Life-threatening Hypercalcemia as the First Manifestation of Acute Lymphoblastic Leukemia

Hypercalcemia of malignancy, usually reported in adults in advanced stages, is rare in children. A 4-year-old boy presented with intermittent episodes of severe hypercalcemia, which improved with intravenous hydration therapy, furosemide and bisphosphonates as the initial manifestation of occult acute lymphoblastic leukemia. Pediatricians should rule out hematological malignancy in patients with severe hypercalcemia.