Low Pth High calcium Normal tests

My DH has been hospitalized twice for hypercalcemia in the past 6 months (levels 14, 13).Both times his Pth is almost nonexistent at less than 0.25 which rules out a parathyroid tumor. Head to toe bone scans and bone xrays are normal as are abdominal and chest Ct scans and chest xrays and abdominal ultrasounds. Ruled out Familial type of hypercalcemia, ruled out multiple myeloma as well as pancreatic cancer, thyroid and parathyroid cancer, bone cancer, chest cancer. His spleen is enlarged. There is a small kidney stone and a small cyst on his kidney they weren't worried about. Not of Jewish descent. Feels ok, gets tired quickly but he's working hard still. He has appt to see hemo/onco doc soon. Docs seem stumped. Any insights folks?

[SassyLassie]

Hello~You say his spleen is enlarged? Well the spleen can sometimes cause problems, have you seen an endocrinologist for his problems?

[Red_Star]

Hypercalcemia of malignancy virtually always show low or undetectable levels of intact PTH.  Rarely, low or undetectable levels of intact PTH with hypercalcaemia can be due to primary hyperparathyroidism with parathyroid adenomas.

One study concludes the diagnosis of primary hyperparathyroidism should be pursued despite suppressed or low-normal serum intact PTH levels after carefully excluding other causes of hypercalcaemia.  "Very low or undetectable intact parathyroid hormone levels in patients with surgically verified parathyroid adenomas." PMID: 18284640.

Another study documents a rare case of isolated granulomatous disease of the spleen presenting as hypercalcemia.  The conclusion stated sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia. " 'Surgical cure' for non-parathyroid hypercalcemia." - PMID: 19254358.

A variety of disorders can cause the spleen to enlarge, sometimes to 2kg (roughly 4lbs) or more.

Causes includes:

Infections
Infectious mononucleosis (EBV or CMV), "glandular fever"
Other viral infections
Parasitic infections
Cat scratch disease
Bacterial infections
Liver diseases
Cirrhosis (portal vein obstruction, portal hypertension)
Sclerosing cholangitis
Wilson's disease
Biliary atresia
Cystic fibrosis
Haemolytic anaemias
Thalassemia
Haemoglobinopathies
Haemolytic anaemia due to G6PD deficiency
Idiopathic autoimmune haemolytic anaemia
Immune haemolytic anaemia
Cancers
Leukaemia
Lymphoma
Hodgkin's disease
Sarcoidosis
Sickle cell splenic crisis
Banti's syndrome
Felty syndrome

Hypercalcemia causes:

Most common (malignancy and primary hyperparathyroidism account for
90% of hypercalcemic patients):

Primary hyperparathyroidism
Malignant disease
PTH-related protein (carcinoma of lung, esophagus, head and neck,
renal cell, breast, ovary, and bladder)
Ectopic production of 1,25-dihydroxyvitamin D (lymphoma)
Lytic bone metastases (multiple myeloma, hematologic
malignancies and breast carcinoma)
Other factor(s) produced locally or ectopically

Uncommon:
Endocrine disorders
Thyrotoxicosis
Granulomatous diseases
Sarcoidosis
HIV
Drug-induced
Vitamin D
Thiazide diuretics
Lithium
Estrogens and antiestrogens
Androgens (breast cancer therapy)
Aminophylline
Vitamin A
Aluminum intoxication (in chronic renal failure)
Miscellaneous
Immobilization
Renal failure (acute and chronic)
Total parenteral nutrition

Rare:
Endocrine disorders
Pheochromocytoma
Vasoactive intestinal polypeptide-producing tumor
Familial hypocalciuric hypercalcemia
Granulomatous diseases
Tuberculosis
Histoplasmosis
Coccidioidomycosis
Leprosy
Miscellaneous
Milk-alkali syndrome
Hypophosphatasia
William’s syndrome
Rhabdomyolysis (presentation is usually preceded by a hypocalcemic
state)

[Red_Star]

The causes of hypercalcemia needs a few spaces. :)

Most common (malignancy and primary hyperparathyroidism account for
90% of hypercalcemic patients):

Primary hyperparathyroidism

Malignant disease:
- PTH-related protein (carcinoma of lung, esophagus, head and neck,
renal cell, breast, ovary, and bladder)
- Ectopic production of 1,25-dihydroxyvitamin D (lymphoma)
- Lytic bone metastases (multiple myeloma, hematologic
malignancies and breast carcinoma)
- Other factor(s) produced locally or ectopically

Uncommon:

Endocrine disorders:
- Thyrotoxicosis

Granulomatous diseases:
- Sarcoidosis
- HIV

Drug-induced:
- Vitamin D
- Thiazide diuretics
- Lithium
- Estrogens and antiestrogens
- Androgens (breast cancer therapy)
- Aminophylline
- Vitamin A
- Aluminum intoxication (in chronic renal failure)

Miscellaneous:
- Immobilization
- Renal failure (acute and chronic)
- Total parenteral nutrition

Rare:

Endocrine disorders:
- Pheochromocytoma
- Vasoactive intestinal polypeptide-producing tumor
- Familial hypocalciuric hypercalcemia

Granulomatous diseases:
- Tuberculosis
- Histoplasmosis
- Coccidioidomycosis
- Leprosy

Miscellaneous:
- Milk-alkali syndrome
- Hypophosphatasia
- William’s syndrome
- Rhabdomyolysis (presentation is usually preceded by a hypocalcemic
state)

[ruralmailmanwife]

Thank you Red_Star for your ideas-some of which my research did not turn up. Most of which the doctors ruled out. I am intrigued with the cat scratch disease idea..... hmmmm We shall see.. Thank you again.