Not as sick as her numbers

A slender 72-year-old woman was referred for evaluation of transient severe hypercalcemia — 13.4 mg/dL — which happened three weeks earlier and resolved quickly with rehydration. On the day I saw her, she had no clinical symptoms or abnormal findings on examination, and her background medical history was quite bland. She enjoyed good health, had no previous surgeries and was on no prescription medication.

The calcium had been stable at 9.8 mg/dL on three occasions post-discharge from hospital, but I was struck by the sedimentation rate that was between 56 and 104 on three occasions over the last four months, and the hemoglobin hovered around 10 with normal red blood cell indices.

My initial thoughts were granulomatous disease, myeloma or lymphoma. There aren’t many other possible causes for transient severe hypercalcemia in a “well” patient, and the sed rate was quite disturbing.

The angiotensin-converting enzyme level was normal as was the urine calcium excretion, but this does not really narrow the differential diagnosis, particularly since she was now normocalcemic. The alpha 1 globulin was 0.6 g/L (reference 0.2-0.4), and the alpha 2 was 1.0 g/L (reference 0.5-0.9). None of the other proteins were suppressed. Imaging studies were interpreted as showing a 2.6 × 2.9 cm new (since 2007) mediastinal lymph node and “granulomatous disease” in the spleen. To me, that also does not narrow the diagnostic possibilities too much.

She remains clinically well, normocalcemic and doesn’t really know what the concern is all about.

It’s not really fair to ask you to comment on a patient with such limited information, but I will do so anyway.

The correct diagnosis will be revealed under the microscope, but what would you recommend be biopsied?