Eclampsia as the First Manifestation of Primary Hyperparathyroidism: a Case Report

BACKGROUND

This study aimed to explore the diagnosis and treatment strategies of eclampsia during pregnancy and postpartum acute pancreatitis caused by primary hyperparathyroidism.

METHODS

This study reported a 26-year-old patient who had maternal eclampsia as her first symptom and was admitted to the hospital. The pregnancy was terminated by cesarean section immediately. Postpartum life-threatening complications, such as severe hypercalcemia and acute pancreatitis, occurred afterward. Following completion of the relevant examination, primary hyperparathyroidism was initially considered to be the cause. Symptomatic treatment is ongoing and will be improved, and the patient will be admitted again for parathyroidectomy.

RESULTS

The patient gave birth to a premature neonate via cesarean section. The postpartum diagnosis was primary hyperparathyroidism, for which post-surgical pathology showed a parathyroid adenoma.

CONCLUSIONS

The clinical manifestations of pregnancy with primary hyperparathyroidism are atypical but may cause serious maternal and fetal complications. Early diagnosis and appropriate treatment can prevent serious prenatal and postnatal complications and foster better pregnancy outcomes.

Hypercalcemic crisis as a presentation of primary hyperparathyroidism

Hyperparathyroidism-induced hypercalcemic crisis (HIHC) is an unusual state of marked progressive primary hyperparathyroidism (PHPT). Patients have severe hypercalcemia and may have severe symptoms such as kidney failure, acute pancreatitis, and mental changes. PHPT is due to the presence of a single gland adenoma/ disease in 80 to 85%; parathyroid carcinoma is reported in <1%. Among patients with adenoma, atypical parathyroid tumor can be found infrequently. Parathyroidectomy is the only curative approach for PHPT. In this report we present three cases of HIHC due to giant parathyroid adenomas (GPAs), one of them with histopathological characteristics of an atypical parathyroid tumor, with satisfactory evolution after parathyroidectomy.

Cancer-related hypercalcemia and potential treatments

Cancer-related hypercalcemia is a common finding typically seen in patients with advanced cancer and occurs in about 20 to 30 percent of cases. The most common cause of hypercalcemia in hospitalized patients is hypercalcemia due to malignancy.This clinical problem is seen in patients with both solid tumors and patients with hematologic malignancies. Hypercalcemia is associated with a poor prognosis in oncology patients. This pathologic condition can occur due to many different mechanisms but is usually caused by abnormal calcium use resulting from bone resorption, intestinal absorption, or renal excretion. Hypercalcemia may present with a wide range of symptoms ranging from gastrointestinal system symptoms to neurologic symptoms. Timely diagnosis and initiation of treatment by the physician significantly reduce the risk of complications. Treatment aims to decrease serum calcium by increasing calciuresis, decreasing bone resorption, and decreasing intestinal calcium absorption. The mainstays of treatment are IV hydration, bisphosphonates and calcitonin, denosumab, and in some patients, prednisone, and cinacalcet. Patients with underlying advanced kidney disease and refractory severe hypercalcemia should be evaluated for hemodialysis. Every physician dealing with oncology patients should know the fastest and most effective management of hypercalcemia. We aimed to contribute in this sense.

Multiple myeloma with unexplained isolated anaemia in a 24year old man- a case report

Background: Multiple myeloma (MM) is a disease of the elderly with a median age at presentation of 70 years. It is rare to diagnose MM in individuals less than 40 years and even extremely rare in those less than 30 years of age. MM is usually suspected in those aged 50 years and above having a combination of hypercalcemia, renal insufficiency, anaemia and bone lesions. Although anaemia is a common clinical feature of MM, it is very rare that anaemia would be the only clinical presentation, hence the need to report this index case. Case Presentation: We present a rare case of MM in a 24-year- old male who presented with only symptomatic anaemia.Investigations for the cause of anaemia, including Bone marrow aspiration cytology revealed a diagnosis of MM ISS stage II.Here, we highlighted the need to seek early haematologist consultation in investigating patients’ whose cause of anaemia is notimmediately obvious from the clinical presentation and routine laboratory investigations. Conclusion: MM can present at a younger age with unexplained anaemia without bone pains or renal insufficiency. High level of suspicion for MM is required in young patients with unexplained anaemia Keywords: Multiple myeloma; isolated anaemia; young patient.

Familial hypocalciuric hypercalcaemia type 1 caused by a novel heterozygous missense variant in the CaSR gene, p(His41Arg): two case reports

BACKGROUND

Familial hypocalciuric hypercalcaemia (FHH) is a rare, inherited disorder of extracellular calcium sensing. It is clinically characterised by mild to moderate parathyroid hormone dependent hypercalcaemia, an autosomal dominant pattern of inheritance, and a normal to reduced urinary calcium excretion in spite of high serum calcium.

CASE PRESENTATION

We report two cases of FHH in a family caused by a novel pathogenic missense variant in the CaSR gene, p. His41Arg. Case 1, describes a 17 year old female with no significant past medical history, admitted with acute appendicitis requiring laparoscopic appendectomy and reporting a six month history of polydipsia. Routine investigations were significant for hypercalcaemia, corrected calcium 3.19 mmol/L (2.21-2.52mmol/L), elevated parathyroid hormone of 84pg/ml (15-65pg/ml) and a low 24-hour urine calcium of 0.75mmol/24 (2.50-7.50mmol/24). She was initially managed with intravenous fluids and Zolendronic acid with temporary normalisation of calcium though ultimately required commencement of Cinacalcet 30 mg daily for persistent symptomatic hypercalcaemia. Genetic analysis was subsequently positive for the above variant. Case 2, a 50-year-old female, was referred to the endocrine outpatient clinic for the management of type 2 diabetes and reported a longstanding history of asymptomatic hypercalcaemia which had not been investigated previously. Investigation revealed hypercalcaemia; corrected calcium of 2.6 mmol/L (reference range: 2.21-2.52 mmol/L); PTH of 53.7ng/L (reference range: 15-65 ng/L) and an elevated 24-hour urine calcium of 10 mmol/24 (2.50-7.50 mmol/24hr) with positive genetic analysis and is managed conservatively. Despite sharing this novel mutation, these cases have different phenotypes and their natural history is yet to be determined. Two further relatives are currently undergoing investigation for hypercalcaemia and the family have been referred for genetic counselling.

CONCLUSION

Accurate diagnosis of FHH and differentiation from classic primary hyperparathyroidism can be challenging, however it is essential to avoid unnecessary investigations and parathyroid surgery. Genetic analysis may be helpful in establishing a diagnosis of FHH in light of the biochemical heterogeneity in this population and overlap with other causes of hypercalcaemia.

Analysis of Time to Diagnosis and Outcomes Among Adults With Primary Hyperparathyroidism

IMPORTANCE

Despite access to routine laboratory evaluation, primary hyperparathyroidism (PHP) remains underdiagnosed and undertreated.

OBJECTIVE

To determine the consequences associated with missed diagnoses and prolonged time to diagnosis and treatment of PHP.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study of patients older than 40 years with 2 instances of hypercalcemia during 2010 to 2020 and 3 years of follow-up. Patients were recruited from 63 health care organizations in the TriNetX Research Network. Data analysis was performed from January 2010 to September 2020.

EXPOSURES

Elevated serum calcium.

MAIN OUTCOMES AND MEASURES

Existing symptoms and diagnoses associated with PHP (osteoporosis, fractures, urolithiasis, major depressive disorder, anxiety, hypertension, gastroesophageal reflux disease, malaise or fatigue, joint pain or myalgias, constipation, insomnia, polyuria, weakness, abdominal pain, headache, nausea, amnesia, and gallstones) compared in patients deemed high-risk and without a diagnosis and matched controls, and those who experienced times from documented hypercalcemia to diagnosis and diagnosis to treatment within or beyond 1 year.

RESULTS

There were 135 034 patients analyzed (96 554 women [72%]; 28 892 Black patients [21%] and 88 010 White patients [65%]; 3608 Hispanic patients [3%] and 98 279 non-Hispanic patients [73%]; mean [SD] age, 63 [10] years). Two groups without a documented diagnosis of PHP were identified as high risk: 20 176 patients (14.9%) with parathyroid hormone greater than or equal to 50 pg/mL and 24 905 patients (18.4%) with no parathyroid hormone level obtained or recorded explanation for hypercalcemia. High-risk patients experienced significantly increased rates of all associated symptoms and diagnoses compared with matched controls. Just 9.7% of those with hypercalcemia (13 136 patients) had a diagnosis of PHP. Compared with individuals who received a diagnosis within 1 year of hypercalcemia, those whose workup exceeded 1 year had significantly increased rates of major depressive disorder, anxiety, hypertension, gastroesophageal reflux disease, malaise or fatigue, joint pain or myalgias, polyuria, weakness, abdominal pain, and headache at 3 years. The rate of osteoporosis increased from 17.1% (628 patients) to 25.4% (935 patients) over the study period in the group with delayed diagnosis. Among those with a diagnosis, 5280 patients (40.2%) underwent parathyroidectomy. Surgery beyond 1 year of diagnosis was associated with significantly increased rates of osteoporosis and hypertension at 3 years after diagnosis compared with those treated within 1 year.

CONCLUSIONS AND RELEVANCE

Many patients were at high risk for PHP without a documented diagnosis. Complications in these patients, as well as those who received a diagnosis after prolonged workup or time to treatment, resulted in patient harm. System-level interventions are necessary to ensure proper diagnosis and prompt treatment of PHP.

Hypercalcaemia secondary to acute rhinovirus infection

Hypercalcaemia-induced rhinovirus has only been reported in a single study in children. Here, we report a case of hypercalcaemia in an adult who tested positive for rhinovirus. This patient underwent an extensive evaluation of hypercalcaemia, and it was found to be mediated by an increase in 1,25 hydroxy-vitamin D that could not be attributed to a cause. Their hypercalcaemia responded to standard treatment with intravascular expansion, bisphosphonates and calcitonin. Serum 1,25 OH vitamin D levels returned to normal with recovery from rhinovirus infection.

Parathyroid adenoma presenting as chronic pancreatitis: A case report and literature review

BACKGROUND

Most patients with parathyroid adenomas are asymptomatic and rarely present with chronic pancreatitis (CP). Several studies have reported a positive association between primary hyperparathyroidism (PHPT) and pancreatitis. Parathyroidectomy is the definitive treatment for PHPT. IV bisphosphonates can be considered the drug of choice for bridge to surgery.

METHODS

We reported a 57-year-old female patient was admitted to the emergency room with left upper quadrant abdominal pain and a diagnosis of recurrent pancreatitis. Magnetic Resonance Cholangiopancreatography confirmed the diagnosis of CP. The patient had no common etiology of pancreatitis. Persistent hypercalcemia was noted despite administering intravenous fluids, and Calcitonin. Intravenous Pamidronate, a Bisphosphonate derivative, was also administered. Although calcium levels initially decreased, they were later found to rebound to previous levels.

RESULTS

A diagnosis of parathyroid adenoma and PHPT was made based on the elevated parathyroid hormone levels and cervical ultrasonography indicated right inferior parathyroid adenoma. Technetium-99m methoxy-isobutyl-isonitrile scintigraphy revealed a focal hot spot of tracer accumulation at the right lower thyroid bed. The patient underwent right lower parathyroidectomy smoothly and successfully. After right lower parathyroidectomy, she had normal serum calcium levels (9.2 mg/dL) and parathyroid hormone (16.1 pg/mL). There was no recurrent abdominal pain after the operation.

CONCLUSION

CP is a rare manifestation of parathyroid adenoma. When patients with a history of recurrent pancreatitis, without common causes of pancreatitis, present persistent elevated serum calcium levels, PHPT could be suspected.

Excluding familial hypocalciuric hypercalcaemia before surgery for primary hyperparathyroidism - a practical evaluation of urinary calcium using a retrospective cohort design

INTRODUCTION

Familial hypocalciuric hypercalcaemia (FHH) and primary hyperparathyroidism (PHPT) are both associated with raised serum calcium and parathyroid hormone (PTH) levels; the former should be excluded in patients undergoing surgery for the latter. Twenty-four-hour urinary calcium collections (24UCA) can be performed to quantify total calcium excreted; however, results of this method do not take into account factors such as kidney function. Current guidelines suggest measuring urine calcium to creatinine clearance ratio (CCCR) as the initial step. The aim of this study was to evaluate the use of CCCR and 24UCA in a cohort design, to reliably exclude FHH patients before surgery for PHPT.

METHODS

A retrospective cohort study of all patients having urine calcium investigations in a single centre, over a 2-year period was performed. Relevant biochemical data and recorded diagnoses were collected.

RESULTS

In total, 296 urine calcium measurements were included from 199 patients. Ten (5%) had genetically confirmed or suspected FHH, 171 (85.9%) had surgically proven or suspected PHPT and the remainder had other diagnoses. At a CCCR cut-off of ≤0.020, positive and negative predictive values (PPV and NPV) were 2.33% and 100%, respectively. At a cut-off of ≤0.015, NPV was maintained at 100% and PPV increased to 3.28%. Low 24UCA measurements (<2.5mmol/L/24h) generated a NPV for FHH of 95.2%.

CONCLUSION

A CCCR measurement below 0.020 should raise the possibility of FHH and genetic screening should be considered. 24UCA had a lower predictive power to exclude FHH (NPV), and measurements should be interpreted in the context of renal function.

Genetics of monogenic disorders of calcium and bone metabolism

Disorders of calcium homeostasis are the most frequent metabolic bone and mineral disease encountered by endocrinologists. These disorders usually manifest as primary hyperparathyroidism (PHPT) or hypoparathyroidism (HP), which have a monogenic aetiology in 5%-10% of cases, and may occur as an isolated endocrinopathy, or as part of a complex syndrome. The recognition and diagnosis of these disorders is important to facilitate the most appropriate management of the patient, with regard to both the calcium-related phenotype and any associated clinical features, and also to allow the identification of other family members who may be at risk of disease. Genetic testing forms an important tool in the investigation of PHPT and HP patients and is usually reserved for those deemed to be an increased risk of a monogenic disorder. However, identifying those suitable for testing requires a thorough clinical evaluation of the patient, as well as an understanding of the diversity of relevant phenotypes and their genetic basis. This review aims to provide an overview of the genetic basis of monogenic metabolic bone and mineral disorders, primarily focusing on those associated with abnormal calcium homeostasis, and aims to provide a practical guide to the implementation of genetic testing in the clinic.

[Hypercalcemia - Diagnosis and Management]

Hypercalcemia - Diagnosis and Management Abstract. The diagnostic workup of hypercalcemia requires a thorough patient history, a focused clinical examination as well as a step-by-step laboratory diagnostic approach. In order to detect the exact aetiology of hypercalcemia an accurate measurement of serum calcium in correlation with the parathyroid hormone level is therefore essential. Primary hyperparathyroidism and malignancy-related hypercalcemia are responsible for about 90% of all hypercalcemia cases. Therefore, these two pathologies should always be considered in the diagnostic approach. The therapeutic procedure is based on the aetiology and severity of the hypercalcemia.

Hypercalcaemia as the initial presentation of Graves' disease

Hypercalcaemia in patients with hyperthyroidism is usually asymptomatic. It occurs due to increased bone turnover and demineralisation. There are only a few case reports where symptomatic hypercalcaemia was the presenting complaint of hyperthyroidism. An Asian man in his 40s presented to us with intractable vomiting for the last 6 months which was not controlled despite multiple antiemetic medications. On routine biochemistry performed at our institute, he was found to have hypercalcaemia and concomitant hyperthyroidism. Classical symptoms suggestive of hyperthyroidism were not present in our patient thus delaying the diagnosis. His symptoms resolved after the correction of hypercalcaemia. Hypercalcaemia did not recur after achieving an euthyroid status on treatment with carbimazole. Other common and more sinister causes for hypercalcaemia like malignancy were ruled out. This case highlights that symptomatic hypercalcaemia could be the initial presentation of hyperthyroidism and amelioration of hyperthyroidism corrects the hypercalcaemia.

Common electrolyte abnormalities in primary care: Hypercalcemia

ABSTRACT

Hypercalcemia is a frequent and often incidental finding in primary care. The most common causes for hypercalcemia are primary hyperparathyroidism and malignancy. Providers should feel confident in progressing through an initial evaluation with appropriate diagnostics, interventions, and suitable and timely specialty referrals.

A case of familial hypocalciuric hypercalcemia type 1 due to CASR p.Pro55Leu mutation

BACKGROUND

Familial hypocalciuric hypercalcemia (FHH) is a rare autosomal dominant disease, which requires differential diagnosis from relatively common primary hyperparathyroidism (PHPT) in order to avoid unnecessary surgery.

CASE PRESENTATION

A 16-year-old female had been followed by the department of psychosomatic medicine at our institution. Throughout the follow-up period, her plasma calcium levels were high, plasma Pi levels were relatively low, and plasma intact PTH was relatively high. She was referred to our department to determine the cause of her hypercalcemia. Her 24 h urinary calcium excretion was as low as 100 mg/day, and calcium creatinine clearance ratio was below 0.01. Moreover, she had a family history of hypercalcemia (proband, her brother, and her father). The genetic testing for her family revealed that she, her brother, and her father were definitively diagnosed with FHH type 1 due to the heterozygous calcium-sensing receptor mutation (NM_00388:4:c.164C > T:p.Pro55Leu).

CONCLUSION

We experienced a 16-year-old female with FHH, in whom genetic testing identified the heterozygous calcium-sensing receptor mutation (NM_00388:4:c.164C > T:p.Pro55Leu) as pathogenic, permitting a definitive diagnosis of FHH type 1. The genetic testing for calcium sensing receptor is beneficial to distinguish asymptomatic primary hyperparathyroidism from FHH.

Hypercalcaemia to hypocalcaemia: tetany as a side effect of intravenous bisphosphonate treatment

A woman in her 40s with advanced bladder cancer was admitted to hospital with hypercalcaemia of malignancy. Initially, she presented with non-specific symptoms of malaise, fatigue and general deterioration. She was treated with intravenous fluids and zoledronic acid in order to bring her calcium levels down, but subsequently developed significant hypocalcaemia. This manifested as tetany in the hands in the form of bilateral carpopedal spasm. She also reported perioral paraesthesia. Bloods during her admission revealed deranged electrolytes, and her vitamin D level was on the lower scale of normal (25 nmol/L). The patient's symptoms improved with electrolyte replacement and oral baclofen for her symptomatically distressing wrist and hand muscle spasms. This case report is a reminder that bisphosphonates can cause significant hypocalcaemia with symptoms of tetany, even when they are given for initial hypercalcaemia. Baclofen worked well to improve symptoms.

Relationship, difference, and diagnostic discordance between blood ionized and total calcium concentrations in client-owned chelonians

OBJECTIVE

To determine (1) the relationship, (2) the difference, and (3) the diagnostic discordance between blood total calcium concentration (tCa) and ionized calcium concentration (iCa) in a population of client-owned chelonian patients.

ANIMALS

161 consecutively admitted client-owned chelonians.

PROCEDURES

Results for tCa, iCa, and other variables were extracted from records. Bound calcium concentration (tCa - iCa) was calculated. General linear models were developed to evaluate factors affecting tCa, iCa and bound calcium concentrations. Diagnostic discordance between tCa and iCa was assessed.

RESULTS

iCa decreased with increasing albumin concentration, it was not influenced by sex, and it was lower in chelonians with disorders of the reproductive tract than in those with disorders of the endocrine/hemopoietic and urinary systems. Total calcium and bound calcium concentrations increased with increasing albumin concentration; they were higher in females and in chelonians with disorders of the reproductive tract. Of the 161 chelonians, 93 (57.7%; 95% CI, 49.7% to 65.5%) would have had a different diagnosis of calcium status based on tCa and iCa results (ie, diagnostic discordance). A 2.2 mmol/L cutoff value for bound calcium could differentiate chelonians with and without disorders of the reproductive tract with a sensitivity (95% CI) of 81.8% (64.5% to 93.0%) and specificity of 76.4% (68.0% to 83.5%).

CLINICAL RELEVANCE

tCa and iCa were related and were associated with albumin concentrations in chelonians. Evaluation of tCa or iCa alone is likely to result in underdiagnosis of alterations of the calcium status. Calculation of bound calcium concentration could help identify chelonians with reproductive disorders.

Parathyroid carcinoma presenting with ventricular bigeminy in pregnancy

Parathyroid carcinoma is very rare in pregnancy. Clinical features are similar to primary hyperparathyroidism. A 38-year-old pregnant woman had repeated hospital admissions for palpitations, headaches, dizziness and polydipsia. Blood investigations showed severe hypercalcaemia with raised parathyroid hormone and 24-hour ECG showed ventricular bigeminy and premature ventricular contractions. Neck ultrasound showed a lesion in the right thyroid lobe. Consequently, she underwent an en bloc resection of the right parathyroid and thyroid lobe at 23 weeks gestation. Histology results confirmed parathyroid cancer. This case highlights the complexities of identifying hypercalcaemia in pregnancy due to the overlapping features with common disorders of pregnancy. Early recognition and timely surgical management can prevent maternal and fetal complications. Also, the case demonstrates the value of interprofessional collaboration between different specialities in providing quality care and improving outcomes. An abridged version of this case was presented at European Congress of Endocrinology 2021.

Successful treatment with denosumab for two cases with hypercalcemia due to vitamin D intoxication and associated acute kidney injury

Hypervitaminosis D is a rare reason for hypercalcemia and associated with acute kidney injury. We report on two cases of hypercalcemia and acute kidney injury because of vitamin D intoxication successfully treated with denosumab. Case 1 is an 83-year-old woman, who was initially treated for 2 weeks with intravenous hydration, steroids and thereafter with furosemide without any effect on serum calcium levels and renal function. Because acute renal failure discouraged us to use intravenous bisphosphonate therapy, we applicated 60 mg denusomab subcutaneously. This led to a prompt reduction in serum calcium levels and improvement of renal function within 1 week. Case 2 is a 45-year-old athletic woman, who refused the standard therapy of steroids and forced diuresis for vitamin D intoxication. After 1 day of rehydration therapy, she received 60 mg denusomab. Similar to case 1 serum calcium declined and renal function improved within 7 days.

AN INFANT WITH IDIOPATHIC HYPERCALCIURIA AND NEPHROLITHIASIS ASSOCIATED WITH CYP24A1 ENZYME POLYMORPHISM: A CASE REPORT

CYP24A1 is an enzyme that inactivates vitamin D and encodes vitamin D 24-hydroxylase. Mutations in this enzyme have been linked with idiopathic infantile hypercalcemia, nephrolithiasis, and nephrocalcinosis. Genetic testing for this mutation should be considered in the presence of calciuria, elevated serum calcium, elevated 1,25- dihydroxyvitamin D, and suppressed parathyroid hormone. We present a previously healthy eight-month-old male infant with macrohematuria, hypercalciuria (6 mg/kg/24 h), albuminuria (54 mg/24 h) and left-sided nephrolithiasis found on urinary tract ultrasound. The values of alpha 1 microglobulin, parathyroid hormone, vitamin D, serum electrolytes, amino acids, glycols, oxalates and citrates in urine, as well as coagulation tests were normal. Genetic testing excluded suspected Dent’s disease but confirmed heterozygous missense variant CYP24A1 c.469C>T, p.(Arg157Trp) classified as polymorphism. He was treated with hydrochlorothiazide and potassium citrate. Children presenting with hypercalcemia, hypercalciuria and nephrolithiasis should be tested because of the importance of recognition, genetic diagnosis and proper treatment of CYP24A1 mutations that can present with a wide range of phenotypic presentations, from asymptomatic to chronic renal disease.

Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?

PURPOSE

Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic.

METHODS

We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments.

RESULTS

The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management.

CONCLUSIONS

In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.