4th Edition

Chapter 25: An achy Iranian woman in a chador

A 58-year-old Iranian woman complained to her GP of aching bones and having to get up at night to urinate. She also had a hoarse voice.

She wore a black chador and her GP wondered about vitamin D deficiency so sent for blood tests.

Her results Normal range
Haemoglobin 106 g/L 120-156
Urea 12 mmol/L 2.9-8.9
Creatinine 136 mmol/L <106
Albumin 28 g/L 30-50
Calcium 4.2 mmol/L 2.12-2.57
25 Hydroxy-vitamin D 28 nmol/L 25-137
Parathyroid hormone (intact) 62 pmol/L 1.2-5.8
  • 1. What is the cause of the hypercalcaemia?

    Correct answer:
    Excess parathyroid hormone.

She had a CT scan of her neck.

  • 2. What does it show?

    Correct answer:

    CT scan of the neck shows a solid mass on the right invading and destroying the right side of the thyroid cartilage. It is compressing the recurrent laryngeal nerve.

She was referred for surgery with en bloc excision of the parathyroid mass and invaded tissues including the thyroid and clinically involved lymph nodes. One day following surgery she develops numbness of both hands and muscle twitches.

  • 3. What is the cause of her symptoms?

    Correct answer:
    The manifestations of hypocalcaemia are summarized by the mnemonic “CATS go numb”. This stands for convulsions, arrhythmias, tetany and numbness/parasthesias in hands, feet, around mouth and lips.

Post-operatively her serum calcium had dropped precipitously to 1.2 mmol/L and she required large quantities of intravenous calcium gluconate.

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