incidental finding of hypercalacemia

RE: incidental finding of hypercalacemia

Andrew Kent — Thu, 07 Feb 2019 16:58:08 GMT

Hi Shona - for sure there are patients who are not treated for various reasons and equally likely many patients that are never diagnosed.

However, this is often a progressive disease with the calcium increasing over time. That means at some point the calcium may well increase high enough to cause problems and, by that stage, any treatment may be more complex due to higher risk of post-op complication and the patient being older.

For that reason I tend to suggest treatment in patients with a convincing diagnosis.

Andy

RE: incidental finding of hypercalacemia

Shona Haydon — Thu, 07 Feb 2019 11:25:26 GMT

Hello, I am interested to read this discussion as I have also been dealing with a patient (13 yr old FN wiemeraner) where hypercalcaemia was identified as an incidental finding. No c/s associated with hypercalcaemia and wanted to seek opinions.

I attended a lecture regarding hypercalcaemia around a year ago, and the lecturer advocated a monitoring approach if older patient, relatively mildly elevated calcium and no associated clinical signs.

Reading texts/literature then surgery or alcholol ablation described so I wondered how many referral clinicians recommended/instituted a monitoring approach.

This patient is otherwise well, but is very stressy so hopsitalistionmay not be fun, but I wouldnt want to do a disservice by advocating no action when intervention is accepted standard of care.

So in summary - from this discussion is it fair to say that in the Uk imaging of neck and surgery still considered first line approach?

Many thanks

Shona

Case: persistent elevated TCa and elevated iCa. Imaging (rads and detailed US but not neck!) unremarkable. PTH high and PTHrp low. TCa around 3.2

RE: incidental finding of hypercalacemia

shanley barber — Thu, 31 Jan 2019 22:30:55 GMT

I would be strongly advising surgery, sooner rather than later, as Andrew said. As far as I am aware, hypercalcaemia will eventually lead to renal failure.

RE: incidental finding of hypercalacemia

Rob Loxley — Thu, 31 Jan 2019 16:13:28 GMT

[quote user="nej41"]Does anyone have any ideas about what the likely prognosis without surgery would be?[/quote]

I've had one that did well with referral surgery, one that did well with referral ultrasound guided ethanol ablation (maybe worth looking at?), and 2 that did well with oral alendronic acid treatment (both for years, 10mg human tablets very cheap). All were hypercalcemic and PTH positive and PTHrp negative.

RE: incidental finding of hypercalacemia

Andrew Kent — Thu, 31 Jan 2019 15:40:42 GMT

[quote user="nej41"]Does anyone have any ideas about what the likely prognosis without surgery would be? I have warned about rubber jaw, and clinical signs of hypercalcaemia developing. [/quote]

We tend to see clinical signs developing eventually and then risk of becoming azotaemic through mineralisation or calcium oxalate obstructions. Those complications can be harder to manage so when asymptomatic is the best time to treat.

Also the risk of post-op problems is lower when the calcium is lower so may be more challenging if left.

[quote user="nej41"]Also, has anyone used medical treatment for primary hyperparathyroidism? [/quote]

There is very little described because it is a disease that can be cured by surgery so little appetite to look into other options.

Andy

RE: incidental finding of hypercalacemia

Beats — Thu, 31 Jan 2019 12:59:16 GMT

in the absence of clinical signs, i think perfectly sensible to leave alone. calcium reno- or uro-liths are probably only potential concern of any significance?

It is, however, fun to remove the glands. as you say some care and risk (read cost/hassle, esp if you dont like on call) in aftermath. calcitriol [cheap as chips, teva i thnik?] started beforehand and slowly weaned probably negates this much in my mind.

here's classic compendium article:

http://www.vetfolio.com/internal-medicine/canine-primary-hyperparathyroidism

RE: incidental finding of hypercalacemia

nej41 — Thu, 31 Jan 2019 11:26:01 GMT

Update:

The owner has opted against surgery due to the risk of post-op hypocalcaemia and also the dog being asymptomatic at present.

Does anyone have any ideas about what the likely prognosis without surgery would be? I have warned about rubber jaw, and clinical signs of hypercalcaemia developing.

Also, has anyone used medical treatment for primary hyperparathyroidism?

Thanks!

RE: incidental finding of hypercalacemia

nej41 — Mon, 28 Jan 2019 10:12:13 GMT

Thanks everyone for all your input! Will get booked in for ultrasound then take it from there

RE: incidental finding of hypercalacemia

Andrew Kent — Sat, 26 Jan 2019 19:31:45 GMT

Agree - this dog has primary hyperparathyroidism and ultrasound of the neck followed by surgery would be the approach of choice. This diagnosis also fits with the lack of current clinical signs as that is often the case.

[quote user="nej41"]2. How reliable is the rPTH test? i.e. do I still need to do a tumour hunt- chest rads and ultrasound abdomen?[/quote]

rPTH is reliable but is only one potential mechanism for malignancy to cause hypercalcaemia so, in other cases, we cannot exclude malignancy by a normal level. However in this case you have an alternative likely explanation so wouldn't feel the need to exclude it further.

Andy

RE: incidental finding of hypercalacemia

Phil Fox-Manning — Sat, 26 Jan 2019 14:10:38 GMT

Totally agree, no tumour hunt needed at present. Might be worth a look at the bladder though just to screen for oxalate urolithiasis.

RE: incidental finding of hypercalacemia

Jenny Harris — Sat, 26 Jan 2019 14:01:45 GMT

How high is the calcium? in the face of hypercalcaemia PTH should be low, so it being high suggests primary hyperparathyroidism and maybe an ultrasound of the neck is the next step ? normal PTHrp doesn’t rule out a paraneoplastic cause, but if this was the case the PTH should be low