What causes insomnia and weakness while on Thyroxin?
You have mentioned that she had a normal thyroid function test before opartial thyroidectomy. What about the thyroid function test after surgery and after stopping Thyroxine ??
Being normal PTH, calcium elevation is not PTH mediated. At this age, we have to think of multiple causes of high calcium. How high is calcium?
Could you please attach full reports ?
Got the report. Unfortunately, the PTH and Thyroid function test reports were not attached.
Looking at the report, she has mild rise in calcium. ( the corrected calcium level is 2.6 mmol). Her ESR and blood glucose also is high.,
The cause of weakness could be due to diabetes itself. If the TSH is elevated, she will need Thyroxin replacement. Hypothyroidism also can lead to weakness.
Lastly, the mildly elevated calcium and rise in ESR, may also point towards some kind of infection or inflammation. You have mentioned that PTH was normal. Hence we have to think about non PTH mediated hypercalcemia ( some infections, some cancers, some inflammatory conditions, dehydration etc can cause rise in ESR and calcium) . At her age, we have to consider all these.
My advice would be to control diabetes first. Add Thyroxine if she has high TSH. Recheck calcium, albumin, PTH and phosphorus in fasting after few days. If calcium and PTH is high, the diagnosis is obvious and we have to do an ultrasound of neck and do a SESTAMIBI Scan. If calcium is elevated and if PTH is normal or low, we may need to do a Chest Xray, serum protein electrophoresis and some bone xrays.
For now, give her fluids to drink. This will reduce calcium levels.
This surely need an endocrine help.
Thyroid function looks normal now. She dosen't need Thyroxine now.
PTH report is not seen in the attachment. However you mentioned that to be normal.
Chest Xray and CT scan of chest is normal, which is reassuring. We need a serum protein electrophoresis as well.
If the repeat test shows normal PTH and elevated calcium, we can also do a PTHrp ( parathyroid hormone related protein).
Need control of blood sugar as well. Noted that Vitamin D is low, but it is best to avoid giving her Vitramin D now till the hypercalcemia is sorted.
Well, high calcium can cause that, but her calcium levels ( corrected calcium) is not that high. Uncontrolled diabetes could be contributing. Does she have any other symptoms like fever or night sweats ?
Is she passing excessive urine? ( that also can contribute to lack of sleep).
Hmm, I am very suspicious of a hidden infection somewhere ( urine/chest/abdomen) . Sorry to say, but my other suspicion is a multiple myeloma or lymphoma ( rare though) with the high calcium with normal PTH and elevated ESR.
The lack of sleep could be multifactorial. The underlying disease + excess urination.
I think she need to be admitted to a good hospital and need a thorough work up
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