Differential Diagnosis for Low PTH and High Calcium
Single Most Likely Diagnosis
- Malignancy-associated hypercalcemia: This is often due to the production of parathyroid hormone-related protein (PTHrP) by tumor cells, leading to hypercalcemia and suppressed PTH levels. Common malignancies include lung, breast, and kidney cancer.
Other Likely Diagnoses
- Vitamin D intoxication: Excessive intake of vitamin D can lead to increased absorption of calcium from the gut, resulting in hypercalcemia and low PTH levels due to negative feedback.
- Familial hypocalciuric hypercalcemia (FHH): A genetic disorder characterized by inactivating mutations in the calcium-sensing receptor, leading to increased PTH secretion and hypercalcemia. However, PTH levels may be inappropriately normal or slightly low in the context of hypercalcemia.
- Lithium therapy: Lithium can increase PTH secretion, but in some cases, it may also lead to hypercalcemia with low or normal PTH levels.
Do Not Miss Diagnoses
- Hypercalcemia of malignancy with PTHrP production and concomitant primary hyperparathyroidism: Although rare, it's crucial to consider the possibility of co-existing primary hyperparathyroidism and malignancy-associated hypercalcemia, as the management and prognosis differ significantly.
- Multiple myeloma: A type of blood cancer that can cause hypercalcemia through various mechanisms, including bone destruction and production of osteoclast-activating factors.
Rare Diagnoses
- Sarcoidosis: A systemic granulomatous disease that can lead to hypercalcemia due to increased conversion of vitamin D to its active form, which enhances calcium absorption. PTH levels are typically low due to negative feedback.
- Williams syndrome: A genetic disorder characterized by hypercalcemia, elfin facies, and intellectual disability. The hypercalcemia is thought to be due to increased sensitivity to vitamin D.
- Jansen's metaphyseal chondrodysplasia: A rare genetic disorder caused by constitutively active PTH/PTHrP receptors, leading to hypercalcemia and skeletal abnormalities. However, PTH levels are typically low due to negative feedback.