Biology 131 Case Studies

Calcium/Phosphate Homeostasis
You will be divided into groups automatically by Canvas. You have approximately 40 minutes to
work on your case studies in class. If you finish the first one, you should move on to the next
one. You may use any source to answer the questions, but I suggest the assigned reading,
your lecture notes, textbook, and Medscape. We will reconvene with ~30 minutes left in class
to discuss both case studies. Please designate a speaker to share your group’s answers.
You must submit your answers for both case studies on Canvas by the beginning of next class.
Your assignment is worth 20 points and will be graded for completion since we will be going
over the answers in class.
Case Study #1
Read the following paper:
Newman DB, Kearns JJ, and Beckman TJ. (2009) 54-Year-Old Woman with Fatigue, Back Pain,
and Hypercalcemia. Mayo Clin Proc 84(12): e9-e12.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2787399/

1. Answer all of the multiple choice questions in the paper as you read it using the information
provided. List your answers to each question here.
a. A
b. A - incorrect, actually D
c. C
d. E
e. B

2. In reviewing the patient’s bloodwork, which parameters were out of range? Were they low or
high?

The patient’s B2- microglobulin levels showed greater than 2.5g/L. The initial bloodwork
showed lower-than-average hemoglobin levels as well as higher-than-normal calcium and
creatinine concentrations. These factors can indicate impaired kidney function. The blood
urea nitrogen is also higher than normal indicating impaired kidney function as well. Lastly,
the erthrocyte sedimentation rate is higher than normal meaning that it can be a marker of
inflammation or tissue damage

3. Most textbooks recommend furosemide as the best initial treatment for this patient. What is
the rationale for this? What is the physiological mechanism of furosemide? Why was
furosemide not recommended for this patient?

Because furosemide works by inhibiting the Na-K2Cl symporter which pushes out most
solutes as well as water this overall reduces bodily fluid volume as well as reduced blood
pressure. If there is greater there average solute level furosemide would reverse that,
 however, in this case because there are indicators that kidney function has been impaired,
the induction of volume depletion would exacerbate the electrolyte imbalance and heavily
affect renal function. Excessive diuresis can potentially worsen hyper calcemia too by
concentrating calcium in the blood.

4. The patient was eventually tested for parathyroid hormone (PTH) levels.
a) Were her levels high, low, or normal?
a. Her PTH levels were far lower than normal.

b) What could hypercalcemia with high PTH levels indicate? Make sure to explain why
there is hypercalcemia and high PTH in this condition.
a. Hypercalcemia with high PTH can result in Primary Hyperparathyroidism. The
parathyroid glands are responsible for calcium level regulation and if there is an
abnormality where they begin releasing great amounts of PTH, then osteoclast
activity will begin breaking down bones to release calcium. PTH also acts kidney
reabsorption of calcium which means that it will not be excreted.

c) What could hypercalcemia with normal or low PTH levels indicate? Name at least 3
conditions and explain why there is hypercalcemia and normal or low PTH in these
conditions.
a. Hypercalcemia with low PTH levels can mean 1 of 2 diagnoses
i. Malignancy associated hypercalcemia
1. Some cancers can produce substances that alter osteoclast
activity causing bone degradation. Some tumors can produce
parathyroid hormone mimics which can cause increased calcium
reabsorption and a decline in phosphate reabsorption. PTH levels
are not elevated.
ii. Hypercalcemia of Granulomatous Disorders
1. Granulomatous disorders like sarcoidosis can lead to
hypercalcemia because of the increase in Vitamin D or Calcitriol.
The macrophages in granulomas activate this. There is greater
calcium absorption and stimulated osteoclast activity. PTH levels
are normal or low.

5. What was the patient ultimately diagnosed with and how were the other differential
diagnoses (from your answers to #4b and #4c) ruled out?
a. The patient was diagnosed with multiple myeloma and the differential diagonses
were ruled out because…
i. Granulomatous Diseases - no abnormal skin or chest radiographic findings.
ii. Histoplamosis - unlikely because hypercalcemia is uncommon in prognosis.
iii. Hyperparathyroidism - common for hypercalcemia but not normal to have
elevated calcium levels than 12 mg/dL
Case Study #2
You are an endocrinologist and have just been referred a 30-year-old lawyer who has
complained to her primary care provider (PCP) for 10 years of chronic fatigue, brain fog, and
depression. Occasionally, she experiences heart palpitations. Her bloodwork over the years is
mostly unremarkable. Notably though, her history shows a normal BMI, normal T3 and T4
levels, and plasma Ca2+ levels that are consistently in the high normal range, just below the
threshold for hypercalcemia. Her PCP diagnosed her with anxiety and occasional panic attacks
as often her heart palpitations are associated with courtroom activities. She has been
prescribed anti-anxiety medications for the last 10 years, which have mostly not helped her
symptoms. She recently experienced extreme muscle cramps, after which her PCP referred her
to endocrinology. On presentation to you, the patient is pleasant, talkative, and denies feeling
anxious in the courtroom. In fact, she adamantly insists that she is as comfortable speaking in
the courtroom as she is to her own family. You send her for bloodwork and T3/T4 levels are still
normal but plasma Ca2+ levels are 11.9 mg/dL, intact parathyroid hormone (PTH) levels are 100
pg/mL, and parathyroid hormone-related peptide (PTHrP) are not detectable.
1. Are her plasma Ca2+ levels low, normal, or high?
a. The calcium levels are higher than normal.

2. What are some symptoms of hypercalcemia that are pertinent to this patient?
a. The chronic fatigue, brain fog, depression, heart palpitations, and muscle cramps are
all pertinent to this patient as increased serum calcium can affect every one of these
functions.

3. How might you explain her heart palpitations and muscle cramps?
a. Increased calcium levels can be disruptive of electrical activity throughout the body
specifically in muscles. So the heart palpitations and muscle cramps are indicative of
increased calcium levels and a direct effect.

4. Considering her PTH and PTHrP levels, what would you diagnose her with? How could you
confirm this? What treatment would you recommend?
a. In regards to her PTH and PTHrP levels, there is not an immediate abnormality
because they are either normal or not detectable. However, the elevated calcium
levels indicate a primary hyperparathyroidism because of a possible overproduction
of PTH. Further screening would be needed to determine that such as imaging of the
neck or doing bone density tests. In regards to treatment, the best choice would be
the surgical removal of parathyroid glands.