An Element Out of Place: The Woman with Hypercalcemia and Lytic Bone Lesions

The patient’s laboratory evaluation was notable for severe hypercalcemia (18.9 mg/dl) and acute kidney injury (creatinine level of 3.94 mg/dl). Suppressed parathyroid hormone (PTH) and undetectable vitamin D metabolites suggested malignancy; however, there was no convincing monoclonal gammopathy, levels of PTH-related peptide were not elevated, and red-cell agglutination was present. Positron-emission tomographic–computed tomography showed widespread lytic skeletal lesions (Figure 1), as well as lesions in the liver and right adrenal gland. Biopsies of an iliac lesion and kidney demonstrated diffuse large B-cell lymphoma.