In this post, we are going to Fatigue, Weakness And Constipation Case Study in Pathology
A 60-year-old woman presents to her GP with several nonspecific complaints. She has been suffering from generalized fatigue for the past few months, as well as muscle weakness. She complains of reduced defecation frequency and 1.5 kg of weight loss in recent months. She has a history of depression, hypertension, and kidney stones.
Physical examination of his cardiovascular, respiratory, and neurological systems is normal. Abdominal examination reveals mild generalized tenderness and possible fecal load. The neck is flexible and insensitive, and there is no lymphadenopathy.
White cells: 6.7
Aspartate aminotransferase: 30
Alkaline phosphatase: 96
Corrected calcium: 2.75
Thyroid-stimulating hormone: 1.5
1.Suggest a differential diagnosis to account for her elevated serum calcium.
2. What further investigations are required to further evaluate this patient?
3. If the cause is related to the parathyroid glands, how should the patient be managed
and what would be the indications to intervene?
Hypercalcaemia is the only abnormality on blood tests and is commonly seen in primary care. It usually presents in a chronic setting and the clinical features can be recalled through the mnemonic of “kidney stones, skeletal bones, abdominal moans, psychic moans.”
There are several possible causes of hypercalcemia:
• Hyperparathyroidism, which may be primary (eg, parathyroid adenoma), secondary (due to renal failure leading to hyperphosphatemia and stimulation of parathyroid hormone [PTH] secretion), or tertiary (parathyroid activity derived from secondary hyperparathyroidism). )
• Malignancy-associated, which may be mediated humorally (eg, PTHrP release from squamous cell carcinomas) or osteolytic (eg, multiple myeloma and bone metastases)
• Vitamin D-related (granulomatous diseases such as sarcoidosis , vitamin D excess)
• Drug-induced (eg, thiazide diuretics)
• Endocrine disorders, including thyrotoxicosis
• Genetic disorders (eg, familial hypocalciuric hypercalcemia, FHH) Of these, the first two are by far , the most common causes, account for up to 90% of cases and therefore require the utmost care when evaluating the patient.
Investigations to elucidate the underlying cause should be preceded by a careful history (including medications) and examination, with an emphasis on examination of the neck (to evaluate the parathyroid glands) and search for a possible tumor (eg, neck examination). chest and breast). A complete blood count is required to look for possible evidence of chronic disease, renal function is needed to identify possible secondary hyperparathyroidism, and phosphate levels may be helpful. A key investigation is measurement of serum PTH, with suppressed PTH levels indicating feedback inhibition of high calcium levels arising from an extraparathyroid source (a possible malignancy).
In this situation, investigation for malignancy (eg, chest radiographs, mammography, and serum and urine electrophoresis for myeloma) would be warranted. Elevated PTH levels would indicate primary (or tertiary) hyperparathyroidism, which can be confirmed by 24-hour urinary calcium measurement. If the above study fails to identify malignancy or primary hyperparathyroidism, attention should be diverted to less common causes of hypercalcemia, including measurement of vitamin D levels and serum ACE levels (for sarcoidosis). Primary hyperparathyroidism is the most common cause of hypercalcaemia and tends to affect older people, particularly women.
The classic “stones, bones, groans, and groans” presentation is quite rare, with most people presenting with several seemingly nonspecific symptoms, including nephrolithiasis, weakness, and mental status changes. The management of this condition is conservative (observation), medical (some evidence supports the use of bisphosphonates and cinacalcet, which inhibits PTH release), or surgical (via parathyroidectomy). Parathyroidectomy is recommended only for symptomatic patients, or for asymptomatic individuals who are young (< –2.5, or previous fragility fracture), or whose serum calcium is 0.25 mM above the upper limit of normal.
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