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Parathyroid pth and calcium problem
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Parathyroid pth and calcium problem

Hello I have added my details below, can tell me if this is primary hyperparathyroid

Age - 23, male
Computer programmer - 8-10 hrs/day, don't go out in the sun

Past history
Following a low carb vegan diet 2-3 years (no dairy sources in the diet)
irritable bowel syndrome
Seizure around age 9-10

Symptoms
obvious - muscle weakness, osteopenia
subtle/occasional - memory problems, general weakness, anxiety, problems passing urine(no urine problems currently)

1st blood test (from Lab company A)

Calcium 11 mg/dl (8 - 10.5)  
Potassium  5 nmol/L  (3.5-5.5)
Serum iron 101.0 ugm/dl (59-158)
Total iron binding capacity 303 ugm/dl         (274-385)
Vitamin D 25 Hydroxy    3.42 ng/ml  (> 30 ng/ml)
Alkaline Phosphatase   353 U/L   (108-306)

Next day (From lab company A)
Calcium ionized 4.8 mgm/dl  (4.0 - 4.8 mgm/dl)
serum magnesium 1.8 (1.70 - 2.70)

I think after 1st blood test I took 2 small vitamin D supplements
which had 200 IU units in each and calcium citrate of 1000 mg.
I took it even before I got the lab results.

I had an 4-5 month old liver function test report which had
Alkaline phosphate 136 units/l (39-117)

2nd Blood test the very next day (From lab company A which outsourced my blood to company B)

PTH, intact   150 (10-65)  pg/ml
Calcium  12 (8.5 - 10.3)  mg/dl

Endo doctor said Lab A and B might be wrong, so let's check it again after 1 week.

3rd Blood test (From lab company C) after 1 week

Calcium, Serum  10.02 mg/DL  (8.10 - 10.40)
Calcium, ionized  1.26 nmol/L (1.16 - 1.32)
PTH, intact     103.80 pg/DL (15.00 - 68.00)

After this test I think I ate some dairy products like milk, eggs etc

4th Blood test (From Lab company C) after 2 weeks

PTh     61.20  pg/ml   (15-68)
Calcium, Serum      10.48   mg/DL (8.10 - 10.40)
Calcium, ionized    1.28   nmol/  (1.16 - 1.32)
Alkaline Phosphate   119.00 U/L  (30 - 120)
Phosphorus           5.00 mg/DL  (2.70 - 4.50)

Sodium 140 meg/L (137-150)
Potassium, serum 4.30 meq/l(3.50-5.30)
Chloride, serum 103 meq/l  (99 - 111)

5th blood test today  (From Lab company C)

Vitamin D, 25 hydroxy   28.80 nmol/L  (> 75 nmol/L)
converts to 11.53 ng/ml (>30 ng/ml)

Phosphorus, serum   4.66 mg/DL (2.70 - 4.50)
Potassium, serum   4.30 meq/l   (3.50- 5.30)
Magnesium serum   2.00 mg/dl  (1.80 - 2.60)

Other tests:

Calcium, 24 hours urine 85.50 (100-300) mg/24 hrs
total volume   4500   (800-1800)  ml/day

Sestamibi scan  = negative

Complete Haemogram

Haemoglobin   13.5   gm%   (13 - 17)
Total leucocyte count  5800  /cumm (4000- 11000)

Different Leucocyte count

POlymorphs  63 %  (40 -80)
LYMPHOCYTES   31 %  (20-40)
EOSINOPHILS     05 %  (1-6)
MONOCYTES   01  %  (2-16)
BASOPHILS      00  %  (1-2)
RBC   4.19  million/cumm   (4.50 -5.50)
platelet count   193000 /cumm  (150000 - 450000)
pcv     39.1 % (40-50)
mcv     93.4 femto litres  (83-101)
mch    32.2 pico grams   (27-32)
MCHC    34.5  G/DL (31.5 - 34.5)
ESR (We stergren)     05   mm/1 hr (5-30)

Peripheral Smear

RBC series        RBCs are normocytic normochromic
WBC series    TLC, DLC Within normals limits NO immature cells seen
PLatelets               Platelets are adequate
Haemoparasites                  No haemoparasites seen
Opinion                  Peripheral blood picture is unremarkable

Liver function test:

Total protein 7.34 g/dl (ref range 6.0 - 8.4)
albumin 4.67 g/dl (ref range 3.5 - 5.5)
globulin 2.67 (1.20 -1.60)
a/g ratio 1.75 (ref range 1.20-1.60)
total bilirubun   0.53  mg/dl  (0.10 - 1.20)
conjugated bilirubin  0.27  mg/dl (0 - 0.70)
unconjugated bilirubin  0.27  mg/dl (0 - 0.70)
sgot (ast)   17 u/L   (5-34)
alk phosphatas  119 U/L   (53-128)
gamma gt  18    u/L  (12-64)

Lipid profile

Cholestrol     136  mg/dl  (ref range 140 -220)
TRIGLYCERILE   70 MG/DL  (20 -150)
HDL - CHOLESTROL   39  mg/dl  (30 - 65)
LDL CHOLESTROL  85   mg/dl  (0-130)

(calculated parameter)

VLDL CHOLESTEROL   14  mg/dl  (ref range 5 -40)
LDL / HDL RATIO   2.18              (0 - 3.55)
CHOL/ HDL RATIO  3.49            (0 - 4.97)

Biochemistry

Blood sugar fasting   91  mg/dl  (ref range 70 -110)
urine sugar fasting    N.R

Blood sugar PP   95 mg/dl (ref range 80 -140)
urine sugar PP   N.R

Blood urea   17 mg/dl   (17 -55)
serum creatinine   0.65   mg/dl  (0.30  -1.30)
uric acid     4.73 mg/dl   (3.50 - 7.20)
Tags: PTH, parathyroid, hyperparathyroid, primary hyperparathyroid, calcium, Vitamin D Deficiency, fluctuation, luctuating PTH levels, Thyroid, calcium metabolism, adenoma
29 Comments Post a Comment
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Avatar_m_tn
After 3 days following 4th blood test I also checked calcium again

Calcium, serum 9.97  mg/dl  (8.10 - 10.40)

Iron  191 ug/dl   (65-175)
total iron binding capacity   346 ug/dl (250-425)
transferrin saturation   55 %    (20-50)
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1756321_tn?1377771734
Over 99% of all cases of high calcium is due to a small tumour on one of the parathyroid glands causing hyperparathyroidism. The key to making the diagnosis of hyperparathyroidism is repeated serum calcium, ionized calcium, and PTH. Healthy people will have the very constant labs from week to week but hyperparathyroidism will show calcium and PTH levels that go up and down from day to day, week to week.

Vitamin D deficiency causes muscle weakness and osteopenia to name but two symptoms.  Vitamin D deficiency is very common with hyperparathyroidism as the body is trying to limit the amount of calcium absorbed from the diet. Vitamin D is essential for calcium absorption.  If calcium levels are above 11.5 mg/dL, taking additional vitamin D can make your calcium go above 12 mg/dL and this may cause a stroke.

As you are a vegan, it is recommended to take B12 supplements (sublingual form). 80% of vegans are B12 deficient. Your slightly elevated MCH may be the early signs of this deficiency showing up.
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Avatar_m_tn
How much is normal calcium fluctuations ?

If calcium is 10.02 mg/dl and then next week its 10.48. Is that normal ?
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Avatar_m_tn
And also I do occasionally get muscle twitching on legs. It feels like something is moving inside the skin.
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Avatar_m_tn
It says "Teens and young adults in their 20's who are building bone can have calcium levels up to 10.7 on more than one occasion."

So it looks like I have secondary parathyroid ?

http://www.parathyroid.com/hyperparathyroidism-diagnosis.htm
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Avatar_m_tn
Well, on this page it says " It is normal for young adults in their twenties to have calcium levels up to 10.3 or 10.4.". That seems contradictory.

http://www.parathyroid.com/parathyroid-function.htm
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Avatar_m_tn
Got new report today:

Calcium , total 10.30 mg/dl (8.80 - 10.60)
calcium, ionized 1.23  nmol/L  (1.16 - 1.32)

pth  51.40 pg/ML  (15 - 68)
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1756321_tn?1377771734
I had my PTH and calcium measured 18 days apart. I had severe magnesium deficiency at the time causing hypoparathyroidism. Even so, PTH and calcium fluctuations were minimal.  

PTH fluctuation: 3 mmol/L
Serum calcium fluctuation: 0.07 mmol/L
Corrected calcium fluctuation: 0.01 mmol/L.

I also had vitamin D deficiency: 30 mmol/L (12 ng/mL). Magnesium is the most important co factor for vitamin D absorption.  Muscle twitching is common with electrolyte imbalances. Electrolytes include potassium, sodium, calcium, magnesium.  

Secondary hyperparathyroidism is typically due to chronic renal failure although vitamin D deficiency can also cause this.  Secondary hyperparathyroidism usually shows up as low or normal calcium and elevated PTH.
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Avatar_m_tn
Okay, I got the original paper from Endocrine Practice Journal by James Norman.
On page 387, read the 3rd paragraph.

http://parathyroid.com/CA%20PTH%20VTD%20PHPT%20NORMOGRAMS%2010000%20PATIENTS.pdf

It says "Before the first calcium measurement over 10.2 mg/DL (before the development of hypercalcemic PHPT), patients showed little diffrences from once calcium measurement to another (mean variability 0.19 ± 0.09 mg/dL). The variability more than doubled to 0.4 ± 0.33 mg/DL in those same patients when PHPT was evident (P<.001)"

So that means calcium can fluctuate between 0.07 to .73 in PHPT patients but in
normal patients it fluctuates between 0.1 to 0.28, right ?

My calcium indeed had gone down from 10.02 to 10.48 and then to 9.97 and
then again to 10.33 which equals to  0.46 variability in first case and 0.51 variability
in next one and then down by .36 points in last report. So what if
the 4 small vitamin D i took are making this fluctuations ? Or my lack of dairy sources
in the diet(vegan) are making this - for example maybe whenever I eat calcium foods
the calcium goes down ?
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1756321_tn?1377771734
My serum calcium fluctuation of 0.07 mmol/L converts to 0.28 mg/dL.

As you have also stated, normal serum calcium fluctuations in the study was 0.1 - 0.28 mg/dL and more than doubled with primary hyperparathyroidism to 0.07 - 0.73 mg/dL.

In my opinion, i don't think taking vitamin D supplements will cause serum calcium fluctuations. There may be a study to show otherwise however.  As you are a vegan, your diet is most likely full of calcium rich foods.

Top 10 foods highest in calcium:

#1: Dried herbs
#2: Cheese
#3: Sesame seeds
#4: Tofu
#5: Almonds
#6: Flax seeds
#7: Yoghurt, milk, and other dairy products
#8: Green leafy vegetables (turnip, mustard, dandelion greens, collards, kale)
#9: Brazil nuts
#10: Herring
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Avatar_m_tn
I think you'll find this info to be of interest.  

http://www.parathyroid.com/low-vitamin-d.htm

Please take special notice of this.

"If your endocrinologist tells you that your calcium is high because your Vitamin D levels are low... and wants to give you Vitamin D to make your calcium go down... then you should print this page and take it to them. This is wrong."

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Avatar_m_tn
No my diet was not high in calcium right foods in around last 2 years. In vegan diet I eliminated diary foods but I also made a mistake to not include any calcium supplements. That is also one explanation which PHPT patients don't have, another explanation is I don't have any symptoms other than muscle weakness and some osteopenia in dexa report. So PHPT patients are probably were eating calcium right foods but I was not even eating that in last 2 years.

My endo said that most of the parathyroid.com patients are americans and Indians living in India don't share the same phenomenon.
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Avatar_m_tn
I had problems passing urine multiple times in last 2 years and we even did ultrasound to find if there was any stone but we found no stones and I still occasionally get problems passing urine like 1 time every 2 months but right now I don't have it so endo did not consider that as my symptom.
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Avatar_m_tn
Also did parathyroid.com patients were getting sun and vitamin D in their past history before they got PHPT ? Most of my time is spent indoors in last 3-4 years and I've been on vegan diet for last 2 years with no calcium or dairy sources and no calcium supplements.

So that is also another information that contradicts with parathyroid.com
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Avatar_m_tn
Most common foods in last 2 years in my diet were

1. http://en.wikipedia.org/wiki/Chapati
2. http://en.wikipedia.org/wiki/Dal
3. mixed vegetables, beans, legumes, Calabash, Winter melon/gourd
4. only recently in last 4 months some nuts - peanuts, cashew,
5. mixed juice (sweet lime, pomegranate)
6. raw fruits - apple, kiwi, coconut water/meat

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1756321_tn?1377771734
An orange contains 50mg of calcium for instance so it depends on what you ate to how much calcium you were consuming.  However, vitamin D levels below 30 ng/mL (75 nmol/L) are associated with a fall in the absorption of calcium from the intestine so the lower the vitamin D levels the less calcium you can absorb regardless of how much calcium is consumed in the diet.

I had calcium deficiency myself with symptoms ranging from yellow teeth to an extremely positive chvostek sign. I could not raise my calcium or vitamin D levels until i corrected my magnesium deficiency.

Hyperthyroidism may cause no symptoms to severe symptoms.  Symptoms are mostly caused by damage to organs due to high calcium or by the loss of calcium from the bones.
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1756321_tn?1377771734
From your list, calcium can be found in beans (depends on the beans as some beans are very high in calcium eg: winged beans 442mg of calcium per 100g serving), depends on the vegetables but some are very high in calcium, legumes, calabash, wintermelon, apples, peanuts, sweet lime, kiwi, coconut water/meat, pomegranate, wintermelon.
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Avatar_m_tn
I read the quoted paragraph below. I forgot to add one more thing other
than being not going out in the sun in last 3-4 years I also did night shift work from 2009-2010 and little bit in 2011-12(when I did work in morning, I did not go out in the sun)  and vegan diet from 2010 and I used to sleep in the morning and work at night. That is contradictory with their medical data.

I think NO, my vitamin d is down because I did not go out in the sun and did night shift work during 2009-2011.

But the data still says calcium should not be above normal. I don't know about that and  would have to check it out. And young people below 25 like me, have higher calcium which parathyroid.com specially says about it. If the first and second blood report is false, then I've 100% secondary and if it is true, then I might have primary. But why would it be false two times. The first time I only measured calcium but in second time I measured pth and calcium.

By the way why has been phosphate high in my reports, isn't it suppose to be low in PHPT. I still get 5 second muscle twitching at arms and legs, maybe that is due to calcium because magnesium is still 2.00 mg/DL (1.80 - 2.60)

His medical data is explaining patients who go out in the sun and get vitamin D from dairy/diet sources like milk, but what about chronic home sitters who work 8 am to 5 pm at home and usually take a walk in the evening when usually there is no sun.

His 85% of patients are older and not younger who sit chronically at home for years. He says body turns off vit D so we don't absorb as much calcium, but
it looks like in my case I turned off vitamin D myself by following a night shift
and by not going out in the sun and following a vegan diet with no dairy and
no supplements. I took vitamin b12 for some weeks during those days but
I stopped after reading this http://skeptics.stackexchange.com/questions/10461/do-supplements-with-folic-acid-cause-cancer-should-they-be-avoided

I was thinking of a supplement which only had vitamin b12 but no folic acid and I did not even bought that due to procrastination and no easy local availability.. It would had been easy if  amazon.com did home delivery of supplements in my country.

" Guess what!?  85% of all patients with LOW vitamin D levels had NORMAL vitamin D levels 3 months after their parathyroid tumor was removed!!  Thus, proving yet another way, the body doesn't like having high calcium which is due to the parathyroid tumor. The body turns off Vit D so we don't absorb as much calcium. When the parathyroid tumor is removed, the body turns the Vitamin D back on and the low vitamin D levels increase back to normal. [1]

The bottom line again:  If your calcium is high, you almost certainly have a parathyroid tumor. If your calcium is high and your Vitamin D is low, you STILL have a parathyroid tumor. If your calcium is high and your Vitamin D is normal, you STILL have a parathyroid tumor.  When you get your parathyroid tumor removed, your Vitamin D level will almost always correct itself within a few months." [1]

[1] http://www.****.com/low-vitamin-d.htm
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Avatar_m_tn
Extended immobilization can cause hypercalcemia or high serum calcium in some patients, according to Lab Tests Online. [1]

Some other causes of hypercalcemia include:

Hyperthyroidism
Sarcoidosis
Tuberculosis
Prolonged immobilization <-----------------------
Excess Vitamin D intake
Kidney transplant

http://labtestsonline.org/understanding/analytes/calcium/tab/test

Looks like now that makes sense because I sit on the computer for
13 hours/day.
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1756321_tn?1377771734
I meant hyperparathyroidism may cause no symptoms to severe symptoms, not hyperthyroidism if anyone reads what i wrote above. :) Your diet isn't that high in calcium as many of the foods on the list contain on small amounts of calcium.

I did miss your phosphate results in all that info. :)  In PHPT, serum phosphate levels are abnormally low however this is only in 50% of cases. Despite higher than normal labs fluctuations, secondary hyperparathyroidism due to vitamin D deficiency (a cause of high phosphate levels) is the most likely diagnosis.  

Just to add, there are conflicting studies on high amounts of folic acid causing cancer. More clinical trials need to be done.
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Avatar_m_tn
Got new reports

20th oct

calcium serum 10.49 mg/dl (8.10 - 10.40)
alkaline phosphate 106 u/L  (30 - 120)

21st oct (I drank alot of water the night before this test, because I had rapid heart beats and felt alot of anxiety/panic. The heart beat was so fast that I was thinking of going to the hospital but I thought drinking water and moving a little bit might be okay; so maybe calcium is low the next day for this reason ? I'm not sure)

Calcium serum 9.90 mg/dl (2.40 - 4.40)
phosphorus     4.70 mg/dl  (2.40 - 4.40)

22nd oct

calcium serum   10.20  mg/dl    (8.10 - 10.40)

Developed some new symptoms

I stopped eating oats, bran as morning breakfast some days back.

On 19th oct I ate 2000 units of vitamin D in tablet form.

On 20th oct - I ate white rice and chickpea and some other stuff.
On 21st oct - I ate white rice and chickpea again at lunch.

On 21st oct I got constipation. Very strong headache in backside of the head(when I shake or move my head it pains very had) so I had to eat combiflam and headache was gone after couple of hours. I had similar headache 2-3 months back and I know it is very bad.I also had some abdominal discomfort. I'm not sure if it was heartburn/GERD/indigestion. But i felt worse.

on 22nd oct - still suffering constipation but feeling okay. I was also feeling some weird thing in the eye. It was not dry eyes like people get from using computers. For 2-3 seconds I was not seeing things clearly and it felt like I was about to fall. I immediately drank 1 big bottle of water and felt okay. Maybe its anxiety or I get too much panicky. I am also being told to get holter monitoring done. I'm feeling like that headache is coming back again

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Avatar_m_tn
btw my blood pressure is normal but i get high heart beats and too much anxiety/panicky
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Avatar_m_tn
And also I felt a little bit flank pain(pain in the right side of the stomach), so I drink full bottle of water and I'm now okay. Water is THE solution to all the symptoms lol
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Avatar_m_tn
I've recently started eating complex cabs(starch) to increase some weight as I've low weight 59.8 kg, 173 cm. Can eating white rice cause headaches ? I've read somewhere that it contains Monosodium glutamate and can trigger headaches ? Or was the headache due to the vitamin d pill I took ?
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1756321_tn?1377771734
Vitamin D uses magnesium to convert to active vitamin D. If you are not eating enough magnesium in the diet, you may develop "side effects" of vitamin D supplementation that are actually symptoms of magnesium deficiency.  There are many possible magnesium deficiency symptoms but they include constipation, headache, heart rhythm problems, anxiety, panic attacks, acid reflux/heartburn.


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Avatar_m_tn
New reports

calcium, serum    10.54   mg/dl   (8.10 - 10.40)
phosphorus    4..93  mg/dl  (2.70 - 4.50)
magnesium   1.70 mg/dl  (1.80 - 2.60)
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Avatar_m_tn
I think after eating oats, my magnesium levels go down. Oats have phytic acid.

"Studies suggest that we absorb approximately 20 percent more zinc and 60 percent more magnesium from our food when phytic acid is absent. This is bad news because phytic acid strongly inhibits mineral absorption in adults – especially iron and zinc." [1]

I don't know why calcium again is high. I've only been eating mostly eggs but no dairy or butter. I occasionally eat butter. But I try to avoid dairy because I get acne. I eat vegetables. I think I'm going to switch to Tahini sauce for calcium.

[1] http://chriskresser.com/another-reason-you-shouldnt-go-nuts-on-nuts

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Avatar_m_tn
Tahini paste is high in calcium but its high in oxalic acid which inhibits calcium absorption. [1]

Where do you get calcium in vegan diet ? Is there something which can be just used like in teaspoon format, I hate cooking. Getting calcium using cooking in not sustainable in my home. I would rather pay for some food which is high in calcium, low in sugar.

[1] www.ohf.org/docs/Oxalate2008.pdf
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Avatar_m_tn
31/oct/12

calcium = 10.6  (8.10 - 10.40)
pth = 36.20 pg/ml  (15 - 68)
vitamin d 25 hydroxy = 32.80 nmol/l   (75-250)
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