Low-trauma Fracture with Hypercalcemia: Need to Look Deeper

Aim: To emphasize the importance of a timely, systemic approach to hypercalcemia to reach an etiological diagnosis. Background: Hypercalcemia is commonly encountered in many individuals, in both inpatient and outpatient settings. Its evaluation entails careful history taking, a battery of investigations to arrive at an etiological diagnosis. Hypercalcemia is more common in adults but not uncommon in children and adolescents. Case description: Here, we present a case of an apparently healthy young male presenting with a nontraumatic vertebral fracture who was incidentally detected to have hypercalcemia. Further evaluation revealed parathyroid hormone (PTH)-independent hypercalcemia. He also had mild anemia and mildly impaired renal function at presentation. During his in-hospital stay, he developed bicytopenia. Bone marrow studies and flow cytometry showed a hypercellular marrow suggestive of acute lymphoblastic leukemia (ALL). Discussion: This case illustrates an uncommon presentation of aleukemic ALL, i.e., low-trauma fracture with PTH-independent hypercalcemia. Conclusion: Hypercalcemia, especially PTH-independent, should entail a high index of suspicion across all age groups for malignancies, including solid tumors and hematological malignancies. Clinical significance: Malignancies, even in younger individuals, can present with low-trauma fracture and hypercalcemia.