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Serum total calcium level high, Vitamin D low, routine blood test. Hyperparathyroidism ?

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Practicing since : 1994
Answered : 19 Questions
I am from saudi Arabia. On a routine blood test I found that was done on 03 July, 2011 it was found that my serum total calcium level was high at 10.8mg/dl and vitamin D was very low at 8.93ng/ml. The last blood test which was done in 23rd XXXXXXX 2010 last year revealed calcium at 9.7mg/dl and was normal. I am really worried over this. From browsing online I found out that it could ne mild hyperparathyroidism. There are not many doctors here who understand this hyperparathyroidism issue. They insist on taking more vitamin D supplements to bring up the D level. But I am afraid it will increase my serum calcium as well. Pls tell me which is the best way I should handle this issue with my doctors.
Posted Sat, 5 May 2012 in Thyroid Problem and Hormonal Problems
Answered by Dr. P.V Pradeep 3 hours later

Thanks for the query.

After going through the description and the reports provided by you, I feel that few more investigations would help us. Please get these following investigations done as this would help us in coming to a conclusion:
1. Fasting Serum Calcium
2. Serum Albumin
3. Fasting Serum Phosphorus
4. Serum Alkaline Phophatase
5. Serum Vit D (25 OH Vit D Fresh report)
6. Serum PTH (Morning sample from reputed lab, sample has to be collected and stored in ice before processing).

Please discuss with your treating doctor regarding these investigations and do write back with the reports to help you with specific suggestions.

If Vitamin D is low then we have to correct it, do not be afraid that serum calcium will increase, if it increases then we will further evaluate.

If hyperparathyroidism is present in the background of low Vitamin D it will show normal serum calcium values, so for the person's best interest we have to first correct it.

Awaiting your response.

Thanks and regards.
Above answer was peer-reviewed by
Follow-up: Serum total calcium level high, Vitamin D low, routine blood test. Hyperparathyroidism ? 29 days later
Dear Doctor,
with regard to the above followup together with my doctor we decided and went ahead with the following tests on the 12th of July. He too agreed that it was necesary to conduct these. All other test results came back on the same day except the vitamin D and PTH which came only yesterday as the samples for these 2 tests had to be sent to another lab. Pls find the following results. All the following tests were with the same blood sample after drawing blood on the 12th morning after 12 hrs fasting.

1. Fasting Serum Calcium - 9.5 mg/dl (8.4-10.2 mg/dl)
2. Serum Albumin - 4.2 g/dl (3.4-5 g/dl)
3. Fasting Serum Phosphorus - 3.1 mg/dl (2.5-4.5 mg/dl)
4. Serum Alkaline Phophatase - 55 U/L (54-144 U/L)
5. Serum Vit D (25 OH Vit D Fresh report) - 8.1 ng/ml (20-50 ng/ml)
6. Serum PTH - 1.49 pmol/L (1.6-6.9 pmol/L)
14 pg/ml (17.3-72.9 pg/ml)


What i noted is that calcium has come back in normal range. last time it was 10.8. But PTH is on the lower side. also vitamin D is still low.

kindly advice what could be the problem and the course of action. Also I am planning to visit my doctor in few days time.

Await your reply at the earliest.

Answered by Dr. P.V Pradeep 1 hour later

Thanks again.

PTH levels are elevated in patients who suffer from hyperparathyroidism. In your case, the levels are low. So it does not seem that you have hyperparathyroidism.

Your reports show low Vit D and PTH . Normally if this happens then calcium should be low as low PTH results in hypocalcemia. So the low PTH is of no significance in your case.

Vit D is low which has to be corrected.

Hope my answer is informative and adequate.

Warm regards
Above answer was peer-reviewed by
Follow-up: Serum total calcium level high, Vitamin D low, routine blood test. Hyperparathyroidism ? 4 hours later
Dear Doctor,
Many tks for the reply. I read on the internet that hypercalcemia can be due to hyperparathyrodism associated with high PTH or other causes such as malignancy or hyperthyroidism which are associated with low PTH values. All of the above causes of hypercalcemia can cause a fluctuating calcium level as well as cause a low level in vitamin D. in my case hyperparathyroidism looks very remote. So assuming that still hypercalcemia can be present specially with my first lab test showing a calcium level of 10.8;

1. Should I rule out other causes of non-parathyroid hypercalcemia such as malignancy, hyperthyroidism etc. Specially with hyperthyroidism symptoms such as high pulse rate which is most of the time over 85, premature greying of hair, feeling cold flashes and sweats etc. I have been having these symptoms for the last 18 months or so. Also what about malignancy caused hypercalcemia? Should I be worried about this?

2. In saudi Arabia we cannot find vitamin D supplements alone. It comes fortified with calcium. Is it ok to take this? Can this worsen the hypercalcemia incase if i am hypercalcemic.

3. Upon discussion with my doctor and trying to get vitamin D level corrected through supplements should I monitor the calcium levels on a regular basis during the perdiod of treatment. Incase if I am hypercalcemic the extra load of vitamin D and extra calcium could worsen my hypercalcemia. So should I monitor my calcium levels during Vitamin D intake.

4. What dosage of vitamin D3 would you reccommend in my case.

Would appreciate your reply on the above as it would help me to come to an action course when I XXXXXXX my doctor.

Anticipate your prompt reply at the soonest.

Answered by Dr. P.V Pradeep 4 hours later

Hyperthyroidism can be associated with high calcium levels. But that is very uncommon. Hyperthyroidism can be easily ruled out by doing a thyroid hormone assessment (t3/T4/TSH) in case your local doctor is suspecting it. I cannot say whether U have it or not just by the symptoms you mentioned since all these can be due to the anxiety he has over his suspected disease
Second that hypercalcemia of malignancy will not be fluctuating, it will be always present. The levels of calcium in maliganancy is due to other factors and the calcium levels in maliganancy will not be affected by the correction of Vit D.
Go ahead and correct calcium levels

I use calcirol XXXXXXX 1 poacket to be taken in milk/ juice every week for 5 weeks. Repaeat Vit D after 3 months and take another course. Periodic Vit D testing can be done 6 monthly
While on Vit D after your 5 weeks course is over do calcium levels 3 months after starting the first dose of vit D

Warm regards
Above answer was peer-reviewed by
Follow-up: Serum total calcium level high, Vitamin D low, routine blood test. Hyperparathyroidism ? 8 hours later
Dear doctor. tks alot for the clarification. Out of curiosity just want to know in your experience had you come across any patient similar to my case and reports whos hormone balances were regained after correcting vitamin D?

I didnt quite understand the calcirol takeup you had mentioned. Is it one packet that I have to take daily for 5 weeks or one packet per week for 5 weeks. What is the vitamin D content of each packet? Is this the D3 or the D2 type. Is it fortified with calcium?

Also what do you mean by Repeat Vit D after 3 months and take another course. That means after 5 weeks i will stop the vitamin D intake. Then after 3 months from where I stopped the first course OR is it from my initial date of starting the first course should I be starting the 2nd course. The seconnd course also should be for 5 weeks? For how long should I be taking the vitamin D course oor howmany 5 week courses should I be taking. What is the optimum vitamin D value that I should target foor.

Vitamin D testing should be done monthly or every 6 months?

Then what did you mean by While on Vit D after your 5 weeks course is over do calcium levels 3 months after starting the first dose of vit D. You mean I have to do a calcium level testing after 3 months from the first starting date of my vitamin D course?

Expect your kindlly reply on this regard.

Answered by Dr. P.V Pradeep 4 hours later

Thanks again,

1) Usually when Vit D is low, PTH will be high. But you have a low Vit D as well as PTH. Hence it is likely that the PTH levels are normal in your case.

2) Calcirol XXXXXXX is packet form containing cholecalciferol.. Take 1 packet per week. After 5 such packets which is to be taken over a period of 5 weeks, stop it. It is not fortified with Calcium.

3) The 5 weeks course is not permanent cure for Vit D. Low Vit D levels can happen due to various causes including genetic, envirnmental and dietary factors. In adequate sun exposure is also a reason. Expose 20% of your body that is hands, legs and face and neck for 20mts for at least 2 days a week to sunlight (morning around 11 AM) so that Vit D is synthesised from your skin. Also consume milk 1 glass per day (300ml),

4) Vit D levels to be checked after 6 months of taking the 1st XXXXXXX

5) Vit D levels of > 20ng/ml is the target. You have to take Vit D supplements periodically till adequate amounts are synthesised in the body

I hope the concerns are addressed.

Above answer was peer-reviewed by
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