A 40-year-old woman with hypertension comes to the physician because of excessive thirst, excessive urination, constipation, and a depressed mood. Her medications include hydrochlorothiazide. Laboratory studies show a serum calcium level of 11.0 mg/dL. Which of the following underlying disorders is most likely?
## **Core Concept**
The patient's symptoms of excessive thirst, excessive urination (polyuria), constipation, and depressed mood, along with hypercalcemia (elevated serum calcium level of 11.0 mg/dL) and the use of hydrochlorothiazide, suggest a disorder affecting calcium metabolism. Hydrochlorothiazide is a thiazide diuretic known to cause hypercalcemia as a side effect.
## **Why the Correct Answer is Right**
The combination of hypercalcemia, polyuria, polydipsia (excessive thirst), and the patient's medication regimen points towards **Primary Hyperparathyroidism** as the most likely underlying disorder. Primary hyperparathyroidism is characterized by the excessive production of parathyroid hormone (PTH) by one or more parathyroid glands. PTH increases calcium levels in the blood by promoting its release from bones, increasing its absorption in the gut indirectly (through vitamin D activation), and reducing its excretion in the urine. The elevated PTH levels or the direct effect of hypercalcemia can lead to the patient's symptoms. Thiazide diuretics like hydrochlorothiazide can also contribute to hypercalcemia by decreasing urinary calcium excretion.
## **Why Each Wrong Option is Incorrect**
- **Option A:** Although not specified, if we consider other causes of hypercalcemia like malignancy, it could present with similar lab findings but usually has more systemic symptoms and a more rapid onset.
- **Option B:** Familial hypocalciuric hypercalcemia (FHH) is a benign condition also characterized by hypercalcemia but typically has a familial history and often less severe symptoms.
- **Option C:** Vitamin D intoxication can cause hypercalcemia and the patient's symptoms but usually occurs with significantly elevated vitamin D levels and might not directly relate to hydrochlorothiazide use.
- **Option D:** If another option like sarcoidosis (which can cause hypercalcemia due to increased vitamin D activation) is considered, it would typically present with other systemic symptoms like lung involvement.
## **Clinical Pearl / High-Yield Fact**
A key clinical pearl is that thiazide diuretics can unmask or worsen hypercalcemia, particularly in the context of primary hyperparathyroidism. Therefore, when evaluating hypercalcemia, it's crucial to consider both the patient's symptoms and medication history.
## **Correct Answer:** . **Hyperparathyroidism**