This 79-year-old man presented with generalized weakness and slight confusion. He was found to have hypoglycemia which resolved. Further workup revealed hypercalcemia. A retroperitoneal lymph node biopsy demonstrated large B-cell lymphoma of follicular origin. Differential considerations for the hypercalcemia included primary hyperparathyroidism or malignancy-associated hypercalcemia given the patient's history of prostate cancer.

1. Case and Disease - Discussion

2. Case: 79 y/o African American Male
 Hx of Htn (>30 yrs), DM type 2 (>15 yrs), a. fib, recurrent PE, Prostate CA (5 yrs),
benign recurrent colon polyps, and old leg injury from Motorcycle Accident (10 yrs
ago).
 HPI: Presented to clinic 1/3/21, with generalized weakness and sl. confusion.
Patient was directed to ER for evaluation. He stated he had not eaten much in prior
day and had had a few glasses of wine. ER noted glucose to be 46. Pt. was given
IV dextrose and serial glucose checks revealed glucose level to rise to normal (63,
132, 151). Pt. denied ha, dizziness, fever/chills, n/v, cp, sob, abd pain or changes to
urine/stool.
 PSH: Inguinal hernia repair (2011), Leg surgery MVA (2011), Colonoscopy every 3-5
yrs, Dr. Wiley (2016, 2019), Prostate biopsy (2016), Bilat cataractectomy (2016).

3.  Home medications: rivaroxaban 20mg a day, metformin 1000mg twice a day, Lotrel
5/10mg a day, Amaryl 4mg twice a day, Tenoretic 50/25mg a day, and atorvastatin
20mg a day.
 Allergies: NKDA.
 FH: + Htn, Hyperlipidemia.
 SH: Married; retired factory worker; 5 children; never smoked; occas. glass of wine.
 ROS: Negative for systems of – Gen., Skin, Eyes, Resp, CV, GU.
Positive for – Gen. Malaise; GI: Nausea, Neuro: dizziness and weakness.

4.  VS: BP- 146/74 Pulse 71 RR 20 SpO2% 96 on room air
 Physical: Gen- well nourished
 Skin- Normal color, no lesion, no rash
 Eye exam- no congestion, no discharge, normal conjunctiva
 CV- RRR, no murmur, pulses intact, no rubs, no gallops.
 Resp- normal breathing, normal breath sounds, no rales, no wheezes, clear bilat.
 GI- normo-active BS, no mass, no tenderness, neg Murphy’s sign, nontender to light/deep palpation.
 Neuro- Alert, oriented to time, person, place; memory intact.
 Psychiatry- normal mood and affect.

5.  Labs (1/3/21): WBC 6.8, Hgb 15.7, Hct 46.0 w normal diff
 Na+ 137, K+ 3.9, CO2 31, Cl 97, Ca2+ 12.4*, Phos – 2.3, Cr 0.96, Bun 20, AST/ALT 72*/33, Alk
phos 89, Albumin 4.4, Protein 7.5, Bili 0.8, Troponin <0.012, Lactate 2.0, Glucose 45*, Vit D 22,
TSH – 1.560, Hgb A1c – 5.5.
 Ua – wnl. Covid – Neg. Influenza a/b – Neg.
 CXR- stable chest. No acute findings
 Ecg- NSR,Rate 76bpm, NS ST T wave changes and occas. PVCs.

6. Any differential diagnosis ideas based on
this presentation, thus far?

7.  1) hypoglycemia-corrected in ER
 2) hypercalcemia
 3) gen weakness
 4) hx prostate ca- review of old outpt labs – PSA 0.33 (9/20)
 5) elevated lft

8.  F/u w PCP- pt referred as outpt to heme/onc. Hypercalcemia w/u.
Ace level <5. Ionized Ca2+ 1.74. PTH 88*. After labs obtained endo eval
ordered.
 Admitted again on 2/3/21 – Dehydration, hypercalcemia noted and sl. chest pain.
R/o ACS w/u initiated and CTA done in ER. Pt. had not yet seen heme/onc as
outpatient – consult done. PTH ordered and resulted normal of 61 noted. ESR – 2.
Hemoccult for blood- negative. PSA recheck 0.24. A stable pulmonary nodule
was found on CT of the chest and nonspecific adenopathy to the chest and abd
noted. There was a large retroperitoneal lymph node noted.
 Any further ideas?

9.  Retroperitoneal bx done- revealed Large B-Cell Lymphoma of Follicular Origin

10. Hypercalcemia

11. CHIMPANZEES- High Serum Calcium
pneumonic
 Calcium supplementation
 Hyperparathyroidism
 Iatrogenic immobilization
 Multiple myeloma, Milk alkali synd, Meds ie: Lithium
 Parathyroid hyperplasia or adenoma
 Alcohol
 Neoplasm (ie: Breast/Lung).
 Zollinger-Ellison syndrome
 Excessive Vitamin D
 Excessive Vitamin A
 Sarcoidosis

13. Symptoms review:

14. Symptoms of Hyperparathyroidism