Case Discussion      An 87-year-old woman was sent to the ER of a teaching hospital due to consciousness disturbance in the morning of Sep 1st, 2001, when she was lying in bed and without having breakfast.      She was noted to have hypertension and began regular control with Losartan 1# qd after May 2001. She suffered from hip fracture and underwent surgical intervention in Aug. 2001.      In the ER, her consciousness was disoriented. The blood pressure was 160/80 mmHg and the body temperature was 37.2 ℃. The heart beat was 96 times per minute. The breathing sounds were clear and the cardiac auscultatio was unremarkable. The bowel sounds were hyperactive. The brain CT in ER was negative. The CXR (Fig 1 ) revealed osteopenia but without active lung lesions. The ECG revealed first-degree atrioventricular block.      The laboratory examination showed hypoglycemia (glucose: 33 mg/dl), hyperkalemia ([K+] = 7.0 mmol/l), and renal insufficiency (BUN: 44.1 mg/dl; Cre: 2.77 mg/dl). Six ampules of 50% glucose water (20 cc/amp) and then 10% glucose water were administered. Her consciousness improved but was still disoriented to person and place. Sodium polystyrene sulfonate and calcium gluconate were also given and the [K+] decreased to 5.36 mmol/l on Nov 3. Hypercalcemia (3.41 mmol/l) was found later and she was given intravenous hydration and calcitonin. Then her consciousness became clear.      The plasma intake PTH (iPTH) level was checked and was found to be elevated (571 pg/ml) (normal, 12-72 pg/ml). Increased uptake on subtraction scan (Fig 2) was also noted. Thyroid echo (Fig 3) revealed a parathyroid adenoma with cyst formation. The aspiration cytology (Fig 4 ) showed parathyroid cells. The intact PTH level in the cyst was very high (131500 pg/ml). Operation was suggested and she was therefore transferred to the Department of Surgery. 項 目: WBC RBC HB HCT MCV MCH MCHC PLT 日期 K/μL M/μL g/dL % fL pg g/dL K/μL Sep 4 7.77 3.83 11.6 34.6 90.3 30.3 33.5 346.0         項 目: GLU  UN CRE Na K Cl Ca AST Alb P 日期 mg/dl mg/dl mg/dl mmole/l mmole/l mmole/l mmole/l U/l g/dl mg/dl Sep 1 27.0 44.1 2.77 139.3 7.0 112.0   29.0     Sep 1       138.3 6.24 109.0 3.41       Sep 3       132.6 5.36           Sep 18   24.2 1.8 139.0 4.3 102.0 2.68   3.6 2.16   項 目 日 期 檢驗值 參考值 (單位) iPTH (Blood) Sep 5 571 12 ~ 72 (pg/mL) iPTH (Parathyroid cyst fluid) Sep 11 131500 案例分析 這是一個以意識變化為主的案例，我們除了考慮腦中風，癲癇，心臟血管病變以外，也應考慮血糖問題（高血糖，低血糖），電解質的問題（如低血鈉，高血鈉，低血鈣），以及代謝問題（如尿毒症，肝腦病變）。起初這個病人只治療低血糖，卻忽略了電解質的問題，一直等到血鈣的校正後，意識才獲得完全的改善。在高血鈣中，最重要的鑑別診斷工具為血中intact PTH，此案例intact PTH高，故為primary hyperparathyroidism。再通過一些影像檢查，超音波及細胞學檢查，得知此病人有一個副甲狀腺腺瘤。因已有腎功能之變化及高血鈣引起之意識變化，故開刀為合理之選擇。 繼續教育考題 1. (D) Which condition below can cause altered mental status? A Hypercalcemia B Hypoglycemia C Hepatic encephalopathy D All of above 2. (C) Which is the possible cause of hyperkalemia in this patient? A Use of angiotensin II antagonist B Renal insufficiency C Diarrhea D A + B 3. (D) Which management below is appropriate for hyperkalemia? A Resin B Bicarbonate C Remove predisposing factor D All of the above 4. (D) Which is(are) the possible cause(s) of hypoglycemia in this case? A Drugs B Poor intake C End organ failure, such as liver and kidney D All of the above 5. (B) Which condition below is usually NOT associated with hypercalcemia? A Multiple myeloma B Hypothyroidism C Hyperparathyroidism D Lymphoma 6. (A) Which of the following parameters is most useful for the differentiated diagnosis of hypercalcemia? A Intact PTH B 24 hour urinary calcium loss C Phosphate level D Vit D concentration 7. (A) Which is the most likely cause of primary hyperparathyroidism? A Parathyroid adenoma B Parathyroid hyperplasia C Parathyroid carcinoma D Lithium use 8. (B) Which condition below is associated with a low level of intact PTH? A Lithium usage B Vit D intoxication C Familial hypocalciuric hypercalcemia D Parathyroid adenoma 9. (C) Which management below is NOT appropriate for hypercalcemia? A IV hydration B Biphosphate C Thiazide D Calcitonin 10. (D) For patients with primary hyperparathyroidism, which condition below requires surgical intervention? A History of consciousness change B Renal stone C Renal insufficiency D All of the above