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A Case Report of Concomitant Diagnosis of Multiple Myeloma and Primary Hyperparathyroidism

 

E Deyab, M Esakji, N Rabin, R Menon, G Rayanagoudar, North Middlesex Hospital

 

 

Introduction: Primary Hyperparathyroidism and multiple myeloma are two of the most common causes of hypercalcemia but the concomitant diagnosis of both in one case is rare.

 

Primary hyperparathyroidism (PHPT) has prevalence estimates of one to seven cases per 1000 adults [1-2] It is believed to be the most common cause of hypercalcemia.

 

Abstract: We describe a case of 45 years old Jamaican female who presented with left sided chest pain for a month. CXR showed a pathological left clavicular fracture with a lytic lesion. She was noted to have a serum Ca of 3.26 mmol/L.

Investigations: Corrected Ca 3.26 mmol/L (2.20-2.60 mmol/l), Phosphate 0.60mmol/L (0.87-1.45 mmol/L), PTH 16.8pmolL (1.6-6.9 pmol/L), Vitamin D 26nmol/L (Insufficient if 25-75nmol/L); Paraprotein not detected, kappa light chains 44 mg/L (3.3-19.4 mg/L), lambda light chains 8.5 mg/L (5.7-26.3 mg/L), kappa lambda ratio 5.2 (0.26-1.65), urine-BJP negative and beta-2 microglobulin 4.3mg/L (0.26-1.65), LDH 180 IU/L (135-214 IU/L).

 

Bone marrow: 80% plasma cells on trephine with findings consistent with high risk myeloma.

 

CT CAP: expansile lytic lesion in left clavicle, probable pathological fracture of right fourth rib, multiple lytic lesions in bones and calculus in right kidney. MRI spine showed abnormal signal in multiple vertebrae.

 

US Neck: 1.2 low density structure highly suspicious of enlarged parathyroid gland.

Sestamibi: adenoma in the region of the upper pole of the left thyroid lobe.

PET scan post-chemotherapy showed response to treatment with low-grade mild activity in left clavicle only.

 

Management: Patient was referred for Parathyroidectomy.

Patient was diagnosed with Oligo-secretory Myeloma, revised ISS stage two and primary hyperparathyroidism.

She completed 6 cycles of chemotherapy and received monthly Zoledronic acid. She is awaiting stem cell transplant.

Patient was referred for Parathyroidectomy.

 

Conclusion: Hypercalcemia as a presenting symptom of concomitant MM and Hyperparathyroidism is rare with 30 reported cases (Hussain et al 2013)[3]. Majority were female with age ranging from 45-92 years. Our patient is the youngest to our knowledge.

Parathyroidectomy, chemotherapy and radiotherapy have been used for treatment with variable success. The prognosis has been generally poor with 28% dying within 5 years of diagnosis.

 

 

References

1.    Writing Group for the SEARCH for Diabetes in Youth Study Group, Dabelea D, Bell RA, et al., editors.Incidence of diabetes in youth in the United States. JAMA. 2007;297(24):27162724 [PubMed] [Google Scholar]

2.    Lawrence JM, Lukacz ES, Nager CW, Hsu JW, Luber KM. Prevalence and co-occurrence of pelvic floor disorders in community-dwelling women. Obstet Gynecol. 2008;111(3):678685 [PubMed

3.    Hussain N., Khan M., Natarajan A., Mohammedabdul M., Mustafa U., Yedulla K., and al. A case of multiple myeloma coexisting with primary hyperparathyroidism and review of the literature Case Rep Oncol Med 2013; 2013:420565