Undiagnosed and don’t know where to go next

Posted by beanie300 @beanie300, Nov 7, 2018

I am posting here in hopes that someone out there has experienced something similar or can at least tell me where to turn next when it comes to figuring out my illness. A friend of mine who has lupus said it sounded like it could be autoimmune but I really don’t know anymore!

The following chunk is going to be a long medical history and I apologize, I just want to give as much information as possible in hopes of getting help.

I was born premature but had amazing algae scores and was sent home that day. My mother tells me I was always sick as a baby with chronic throat infections of some kind or other. She made the doctors remove my tonsils before I was 2 in hopes that it would help but it didn’t seem to. Growing up I remember always being sick. I seemed to get every bug going around but was always especially susceptible to strep throat infections and sinus infections. I was sick so much that by highschool I am pretty sure I only was actually able to attend around 2/3 of the total days in the school year. Maybe even less than that and this wasn’t me staying home with colds, this was constant stomach flu, upset respritory infections, and of course strep throat. I also had constant hives and dermatographia since I was young and still have it to this day! The doctors always wrote it off, saying it was probably a food allergy, but never really looked into it. I also never ran fevers as a kid and instead run at a constant 97.6.

In 2016 my constant bad health seemed to take a turn for the worst. Right after graduating highschool I got so sick I was bedridden for the whole summer. I was throwing up, having joint pain, and sleeping all the time. No fever but I NEVER run fevers. After a month of it my mother took me in to my family doctor. She ran a mono test and Lyme test which both came back negative but she was sure it was mono so she told me to come back in a few weeks. I did but the test was negative again, and then again when I came in another month later. My white counts were high but they couldn’t figure out what was wrong other than that. Finally after 4 months I got better and stopped going back to the doctor, just in time for me to go to my freshmen year of college.

I made it through my first semester, despite the fact I got stomach flu and strep a few times but then part way through my second semester I got sick again. I was throwing up to the point I had to be hospitalized for fluids. All of my lymph nodes were so swollen I didn’t even look like I had a neck and was having a hard time swallowing. This time it turned out I actually did have mono. I had to leave my college and go home to recover. It took a total of about 4 months to get better but I never felt 100% again after that. My doctor told me it could take up to a year to feel fully better so I decided to take time off of college and get a job.

The job lasted about three months. I was so tired in that time that I would get up to go to work, struggle through my shift, go home, and immediately go to sleep. I was only awake about 10 hours a day but I figured it was just because I wasn’t used to working and would adjust. Then I started developing severe joint pain and stiffness, to the point that it was hard to get up off the couch simply because I couldn’t unbend. Both of my parents have rheumatoid arthritis so I assumed it was that and went in to my doctor for testing. I was only 20 and knew I shouldn’t be feeling as old as I suddenly felt. She ran an ANA that came back normal. A week later I passed out in the shower. My parents and I assumed maybe the water had been to hit and left it at that. Another week later I passed out at work. The fainting episodes became a normal part of my life which led to me quitting my job.

I went to see my primary physician again but she was clueless. She ran a complete blood count, metobolic panel, and tested me for Addison’s disease. It all came back fine aside from a slightly elevated white blood count. She then referred me to doctor number 2, an internist.

Doctor number 2 was probably the best I had ever seen. Listened to my story then tested me for dermatographia before I had even mentioned the hives or dermatographia. He sent me to an allergist.

Doctor number 3, the allergist. I explained the dermatographia and the fact that I had it, along with hives, since I was a kid. We had never been able to link the hives to any food and explained that sometimes I would break out in hives because of the heat or because of crying or getting stressed. He told me he couldn’t test me with the scratch test because I had dermatographia but that he could test my blood for allergies. He told me he didn’t think this would be helpful however because the would only be able to test for a few things and he said my hives sounded idiopathic. I went home without the test.

I followed up with my internist, doctor number 2, but while the nurse was taking my vitals she found I had a heart murmur. I was sent for an ultrasound of my heart and they found I had a mitral valve prolapse but told me it was nothing to be concerned about. I went back in later for the follow up and the nurse took my vitals and found I had a heart arythmia. They gave me a 24 hour heart monitor. I only actually ended up wearing the monitor for 20 hours because the sticky pad things they used caused my skin to blister up and peel off.

The cardiologist I saw, doctor number 4, told me my heart murmur was benign and then went on to suggest that maybe I was on too many medications due to the fact that I take an anti anxiety, and antidepressant.

Back to doctor number 2, my internist. He gave me two different anti-histamines and sent me home in hopes it would improve my symptoms.

All of my symptoms kept getting worse. I developed brain fog, trouble concentrating, headaches, and none of my previous symptoms improved. I turned to the internet in hopes of figuring out why I was fainting and read about postural orthostatic tachycardia syndrome or POTS for short. I went to my doctor that week and asked if he had ever heard of it. He told me he didn’t think that was what I had, as it was rare, and sent me home. My mother convinced me to go back and demand to be tested, and it turns out I do have POTS. On an average day, my heart rate laying is 55 and it jumps to 130 when I am standing.

Thankfully now that I know what is going on I was able to start managing symptoms and hoped it would help with everything from the fainting to fatigue, joint pain to brain fog.

I started developing new symptoms. My brain seems to scramble words when I read now or it messes up grammar. I have a persistent pain in my left side that doctors can’t explain. My rib cage in the front on my left side also goes through flair ups where it hurts when I breath and I have been developing migraines.

The fatigue got worse until I was only awake about 2-4 hours a day total and all of my lymph glands swelled up again. It felt like when I had mono so I went in to try and figure out what was going on. My internist sent me to doctor number 5, an infectious disease specialist, who told me I had a mono reactivation. At this point it had been exactly a year since I left college with my first bout of mono. He said it was really rare and he wanted to test my immune system. He ran a complete blood count, C-reactive protein test, t-cell test, and a few others. Everything came back normal.

My doctor said he had no idea why I got mono again and seems to have no idea what to do with my other symptoms! I want to ask for more tests but I don’t even know what tests to ask for anymore or what doctors to ask to see and I am afraid they are going to diagnose me as a hypochondriac!

Currently my symptoms are
– dermatographia
– hives (particularly when upset but often without obvious cause)
– migraines
– joint pain
– joint stiffness
– Nausea
– loss of appitite
– brain fog
– trouble concentrating
– extreme fatigue
– vomiting, sometimes without even feeling ill beforehand
– dizziness
– pain in my left side, about where my spleen is, but doctors say my spleen is not enlarged
– pain in my ribs sometimes when I breath that lasts a few hours
– no fevers ever.
-numbness and tingling in my hands and feet at times
– mouth ulcers. (I have had these since I was a kid. The come and go. I sort of get break outs of them)

Anyone have any ideas? Anything helps. I just want to go finish college and move on to my career but can’t do that while I am this sick! I am a 21 year old white female if that helps anything.

@becsbuddy

@hopeful33250 I just saw your message from December! Thank you for the info on Dr. Tobin. At the moment, I’m being treated by a neurologist at University of Colorado and think I’m doing OK. Still trying to find my old self, but think I’ll have to settle for new self. CLIPPERS is pretty rare, less than 100 of us lucky people. Think I’ll give Dr. Tobins name to my neurologist. Thank you for the info and interest. Becky

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@becsbuddy Hello Becky,

I'm glad that you are doing well at the Univ. of Colorado. I understand what you mean when you say, I'll have to settle for my new self. Adjusting to a new normal is a quantum leap, to say the least. It is so good to have you as part of our Connect community. You have given a lot of encouragement to a lot of people.

Just wondering, Becky, how are you being treated for Clippers? Is there a particular med and/or therapy that is helping you?

I'll gladly celebrate with you as you become acquainted with your new self!

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@hopeful33250

@becsbuddy Hello Becky,

I'm glad that you are doing well at the Univ. of Colorado. I understand what you mean when you say, I'll have to settle for my new self. Adjusting to a new normal is a quantum leap, to say the least. It is so good to have you as part of our Connect community. You have given a lot of encouragement to a lot of people.

Just wondering, Becky, how are you being treated for Clippers? Is there a particular med and/or therapy that is helping you?

I'll gladly celebrate with you as you become acquainted with your new self!

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@hopeful22350. You asked about treatment for CLIPPERS. The main one is steroids, but it is difficult to use long term. Caused my osteoporosis! Several patients are using rituxan, a chemotherapy drug, which is not yet approved for this. Others use other chemo drugs. Who knows what the future holds!

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@becsbuddy

@hopeful22350. You asked about treatment for CLIPPERS. The main one is steroids, but it is difficult to use long term. Caused my osteoporosis! Several patients are using rituxan, a chemotherapy drug, which is not yet approved for this. Others use other chemo drugs. Who knows what the future holds!

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@becsbuddy Meds are great, but you always trade one problem for another.

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Hey everyone! just wanted to post an update. I did finally end up going to the Mayo clinic in Rochester after finally finding a doctor who would refer me so that my insurance would cover the visit. Unfortunately they were unable to be as extensive as they would have liked thanks to my insurance not wanting to work with them in a timely manner and me not being able to cover the costs myself. They were very nice there though! Did more testing in the two weeks I was there than most of my doctors have in two years and they even waived the fee on my last appointment to help me handle the cost!

I had a few labs come back abnormal for once which is probably a weird thing to be excited about but after years of doctors knowing I am sick (several times with physical symptoms they were actually able to see for themselves) but normal lab results so they couldn't figure it out, having abnormal lab results has me feeling hopeful for answers!

My vitamin D levels are low. They were an 8 when they tested, with an optimal range being between 20 and 50. They now have me taking 5000 ui of vitamin D for three months and at the end of that three months (which will be the end of this month!) I have to go in to my regular doctor to get those levels retested. If they come back abnormal again then I am supposed to get tested for Celiac disease. They already did the blood test for Celiac disease at mayo but that came back normal. The doctors at mayo told me about 10% of people with Celiac disease have a normal blood test and with all my symptoms, they weren't ready to rule it out until they see how my body absorbs these vitamin D supplements.

My cortisol levels also came back low. A 5 with a reference range of 7-25. I was told I should have been on the higher end of that reference range though because they ran the cortisol test first thing in the morning when my cortisol should have been at its highest. I am also getting my cortisol levels rechecked at the three month mark (the end of this month.) and if it comes back weird again, they will dig further into that.

They also tested my thyroid levels with a TSH test that came back high (4.6 with a ref range of 0.3 – 4.2) indicating I may have some kind of thyroid condition that they caught early. I was told they don't do any treatment however unless those levels come back at at least a 10 because otherwise the medication could hurt more than it would help. I am supposed to go get my thyroid levels retested at the 6 month mark (about 4 months from now) and again at the 12 month mark just to make sure my thyroid levels don't get worse.

A few other results came back a little off but the doctors didn't feel those results held any significance so I won't mention them here.

Additionally, my primary care doctor wanted me to get the sores in my mouth tested for herpes the next time I had an outbreak of 4 or more sores. Due to the circumstances in my life at the time I wasn't able to get that done for the first few outbreaks but I finally got it done. The test results were negative, so not herpes. If I do end up having Celiac Disease then I have been told it could be a symptom of it.

Unfortunately my regular doctor just retired so while dealing with all of this I also have to find a new doctor who will believe me, be helpful, and take my insurance. I have an appointment with what will hopefully be my new primary care doctor in a few days to establish care and get my levels retested.

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@redhead63

Hi:
Did you get your Vitamin B12 checked lately? Please don’t let a Dr. tell you that your Vitamin B12 is normal, your number on your Vitamin B12 should be in the 600-1,000, not 500 or 575 at least 600. I had horrible tingling in my body all over. Once I got my Vitamin B12 up to 600 it all went away. Also get your Vitamin D2 and D3 tested and that number should be at least 50-90, not 25 or 30 at least 50. My number was 9 and I had a lot of symptoms like you, now I keep it around 80. I also have Autonomic Dysfunction and that is cause by my Vitamin B12 and Vitamin D2 and D3 being so low for many years. The damage was already done.

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@redhead63 I have not had my vitamin b12 tested but I have had my vitamin D tested at the Mayo Clinic and it came back an 8. Can low B12 and low vitamin D over a prolonged period cause autonomic dysfunction?

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Do you know if you have had an HLA B27 blood test? Many of your symptoms are similar to what I have had over my lifetime, and I have finally been diagnosed with ankylosing spondylitis. Here are some of the symptoms:

The joint between the base of your spine and your pelvis (sacroiliac)
The vertebrae in your lower back
The places where your tendons and ligaments attach to bones (entheses), mainly in your spine, but sometimes along the back of your heel
The cartilage between your breastbone and ribs
Your hip and shoulder joints

This is a pretty rare autoimmune disease and in addition to the positive HLA B 27 test, spinal x-rays that show "cascading bone" down your spine (though you may be too young yet for this to appear), and positive C-reactive protein or other inflammation indicators cam help confirm the diagnosis.

In addition to the above symptoms, AS symptoms can include irritable bowel syndrome and other digestive difficulties as well as chronic fatigue. (Also, has anyone checked you for diabetes? You need a fasting blood draw to measure not only your glucose level but also hemoglobin A1C. Chronic, severe fatigue can also appear if you have diabetes.

My disease progression over the years started with irritable bowel issues followed by "costochondritis" (severe rib pain in the rib attachments where there is cartilage). sciatic and low back pain, hip pain, diffuse joint pain. Although the symptoms followed one another, all of them continued and were concurrent. I was not diagnosed until I was 65 years old.

I would suggest finding out if your rheumatologist is well versed in ankylosing spondylitis so that he knows how to diagnose and manage the disease. Once the disease is confirmed, you might add a pain management specialist to help deal with these issues. Something you can do yourself is to think about starting yourself on a gluten-free, antii-inflammatory diet.

Here is a web page that might help you understand AS and see if you think this might be your answer:

https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808

Hope this helps. Blessings, young lady.

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@beanie300 I found a few studies that might be of interest regarding low levels of Vitamin B12 and Vitamin D and form your followup from Mayo, you are a bit like me, and the answer to your question is yes. This is good news because you can be proactive now and correct the deficiencies. Thanks for checking back in.

https://jnnp.bmj.com/content/66/6/804.2.full
https://www.sciencedirect.com/science/article/abs/pii/S0306987716303504

I see a functional medicine specialist who has tested my Vitamin D levels and I know how much Vitamin D supplement I need to take. Too much Vitamin D can cause problems like causing Calcium to be deposited in the walls of blood vessels, so it should also have Vitamin K2 along with the Vitamin D to prevent that from happening. I take K2 D3 5000 ui, from Orthomolecular based on my doctor's recommendation, and to get my test results up to 50, I need 2 of these a day.

https://www.thieme-connect.com/products/ejournals/abstract/10.1160/TH08-02-0087

I also have thyroid issues and take desiccated pig thyroid or my thyroid hormones are too low. TSH is a thyroid stimulating hormone and your body's way of saying that it wants the thyroid to produce a little more. When a person needs thyroid medication because of low thyroid function, there are 2 choices, the natural pig thyroid or synthetic thyroid medication that does not have all the components of the natural. With the synthetic version, some patients cannot convert the T3 to T4 (which is a normal thyroid function), and their doctors increase the dosage, but the patients don't feel better. My doctor told me that happens with Graves disease, and they should only be on pig thyroid. This is something to keep in mind if and when you need prescribed thyroid hormones. They can both work, unless you are someone who can't convert the components correctly. Two manufacturers of desiccated Pig thyroid are Naturethroid and Armour. Sometimes the availability of these is scarce. I have had to use mail order with a pharmacy in Tennessee (DCA) that is the distributor for the manufacturer of Naturethroid. At one time, my compounding pharmacy could compound pig thyroid, but for some reason, the materials have been restricted and unavailable.

I also have gluten issues. I never was officially tested for celiac disease because 20 years ago, when I asked my doctor this question, a lot of doctors didn't believe in the existence of the problem. Now it is accepted, but 20 years ago, I tested myself with an elimination diet and challenging with the eliminated foods, and I took gluten out of my life, and my health improved a lot. If I unknowingly made a mistake and had a small amount of gluten, I reacted. This happened with rice milk because of gluten in the enzymes used to produce the product, and when I read the carton it had a small amount of gluten present. If you do want a blood test for celiac disease, that needs to be done while you are exposed to gluten. If you had taken gluten out of your life, it would alter the test results. The inflammation from gluten in a reactive person opens the door to the development of other food allergies because it causes a leaky gut where incompletely digested food is absorbed into the blood stream. This is what happened to me, and once that happens, you live with food allergies and having to avoid a lot of things. It might be better to figure it out now and take a proactive approach to preventing future issues.

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Hello @beanie300,

I am so pleased to hear that you were able to go to Mayo. It sounds as if you got some clues as to what might be going on with your health. Enough clues may eventually lead the doctors to find out what might be going on and then lead to a diagnosis. I'm sure that you are hoping that this is the case.

The Vitamin D level, at 5, was really quite low. This can be indicative of many things, but hyperparathyroidism is one that comes to my mind as I have this problem and it is associated with the parathyroid. Please be aware that the parathyroid is DIFFERENT than the thyroid gland. While the parathyroid is located in the same area, it serves a different function. The name of the test is PTH (or sometimes PTH intact). You might look through your medical records and see if anyone has tested for this. If not, it would be a good idea to ask for this test. If your parathyroid is not functioning correctly it can cause a lot of the symptoms you mentioned.

I'm looking forward to hearing from you again.

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@hopeful33250

Hello @beanie300,

I am so pleased to hear that you were able to go to Mayo. It sounds as if you got some clues as to what might be going on with your health. Enough clues may eventually lead the doctors to find out what might be going on and then lead to a diagnosis. I'm sure that you are hoping that this is the case.

The Vitamin D level, at 5, was really quite low. This can be indicative of many things, but hyperparathyroidism is one that comes to my mind as I have this problem and it is associated with the parathyroid. Please be aware that the parathyroid is DIFFERENT than the thyroid gland. While the parathyroid is located in the same area, it serves a different function. The name of the test is PTH (or sometimes PTH intact). You might look through your medical records and see if anyone has tested for this. If not, it would be a good idea to ask for this test. If your parathyroid is not functioning correctly it can cause a lot of the symptoms you mentioned.

I'm looking forward to hearing from you again.

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@beanie300 @hopeful33250 My mom had an overactive parathyroid problem and it caused her blood calcium levels to be very high and it pulled calcium out of her bones. She had one of the four parathyroid glands removed and they tested blood levels while she was on the operating table to make sure that it was the correct one. Her blood calcium level with the diseased parathyroid intact was 12. Her calcium levels returned to normal after the surgery. Here is Mayo's information about Hyperparathyroidism (overactive).

https://www.mayoclinic.org/diseases-conditions/hyperparathyroidism/symptoms-causes/syc-20356194

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@jenniferhunter

@beanie300 @hopeful33250 My mom had an overactive parathyroid problem and it caused her blood calcium levels to be very high and it pulled calcium out of her bones. She had one of the four parathyroid glands removed and they tested blood levels while she was on the operating table to make sure that it was the correct one. Her blood calcium level with the diseased parathyroid intact was 12. Her calcium levels returned to normal after the surgery. Here is Mayo's information about Hyperparathyroidism (overactive).

https://www.mayoclinic.org/diseases-conditions/hyperparathyroidism/symptoms-causes/syc-20356194

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@jenniferhunter Thanks for those great links!

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@hopeful33250

Hello @beanie300,

I am so pleased to hear that you were able to go to Mayo. It sounds as if you got some clues as to what might be going on with your health. Enough clues may eventually lead the doctors to find out what might be going on and then lead to a diagnosis. I'm sure that you are hoping that this is the case.

The Vitamin D level, at 5, was really quite low. This can be indicative of many things, but hyperparathyroidism is one that comes to my mind as I have this problem and it is associated with the parathyroid. Please be aware that the parathyroid is DIFFERENT than the thyroid gland. While the parathyroid is located in the same area, it serves a different function. The name of the test is PTH (or sometimes PTH intact). You might look through your medical records and see if anyone has tested for this. If not, it would be a good idea to ask for this test. If your parathyroid is not functioning correctly it can cause a lot of the symptoms you mentioned.

I'm looking forward to hearing from you again.

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@hopeful33250 @jenniferhunter do either of you know if there is a genetic link with hyperparathyroidism? My grandmother on my fathers side had it so I was wondering if that could increase my risk. My calcium levels are fine though, can they still look ok with hyperparathyroidism? If so I’ll be sure to ask for the test.

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@beanie300

@hopeful33250 @jenniferhunter do either of you know if there is a genetic link with hyperparathyroidism? My grandmother on my fathers side had it so I was wondering if that could increase my risk. My calcium levels are fine though, can they still look ok with hyperparathyroidism? If so I’ll be sure to ask for the test.

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@beanie300 I checked and found a study about genetic links for hyperparathyroidism. It talks about several different gene mutations that cause different types of hyperparathyroidism so it sounds like some forms of it can be inherited. However, just because a person may have genes to predispose them to something, the genes might not be expressed unless other criteria are met in the body chemistry which is complex.

Here are some links and a study regarding parathyroid disease and genetics. This information talks about high calcium levels in both blood and urine as indicators of a problem. I think only a doctor can really answer what is best in your case, but you can ask questions from this information. I think calcium levels are normal things that are routinely checked in blood and urine tests.

This link shows diagnosis in relation to blood levels of calcium and parathyroid hormones shown in a table.
https://www.parathyroid.com/diagnosis.htm

By clicking the links, they even had an app developed by doctors for diagnosing parathyroid disease. http://calciumpro.com/

There is also a rare condition that causes high blood calcium, but it isn't caused by the parathyroid gland called FHH – Familial Hypocalciuric Hypercalcemia.
https://www.parathyroid.com/FHH.htm

https://www.iofbonehealth.org/osteoporosis-musculoskeletal-disorders/skeletal-rare-disorders/familial-isolated-primary
https://jmg.bmj.com/content/41/3/155.full

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@jenniferhunter

@beanie300 I checked and found a study about genetic links for hyperparathyroidism. It talks about several different gene mutations that cause different types of hyperparathyroidism so it sounds like some forms of it can be inherited. However, just because a person may have genes to predispose them to something, the genes might not be expressed unless other criteria are met in the body chemistry which is complex.

Here are some links and a study regarding parathyroid disease and genetics. This information talks about high calcium levels in both blood and urine as indicators of a problem. I think only a doctor can really answer what is best in your case, but you can ask questions from this information. I think calcium levels are normal things that are routinely checked in blood and urine tests.

This link shows diagnosis in relation to blood levels of calcium and parathyroid hormones shown in a table.
https://www.parathyroid.com/diagnosis.htm

By clicking the links, they even had an app developed by doctors for diagnosing parathyroid disease. http://calciumpro.com/

There is also a rare condition that causes high blood calcium, but it isn't caused by the parathyroid gland called FHH – Familial Hypocalciuric Hypercalcemia.
https://www.parathyroid.com/FHH.htm

https://www.iofbonehealth.org/osteoporosis-musculoskeletal-disorders/skeletal-rare-disorders/familial-isolated-primary
https://jmg.bmj.com/content/41/3/155.full

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@jenniferhunter
Those links provide great information about the parathyroid!

Liked by Jennifer Hunter

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@jenniferhunter

@beanie300 @hopeful33250 My mom had an overactive parathyroid problem and it caused her blood calcium levels to be very high and it pulled calcium out of her bones. She had one of the four parathyroid glands removed and they tested blood levels while she was on the operating table to make sure that it was the correct one. Her blood calcium level with the diseased parathyroid intact was 12. Her calcium levels returned to normal after the surgery. Here is Mayo's information about Hyperparathyroidism (overactive).

https://www.mayoclinic.org/diseases-conditions/hyperparathyroidism/symptoms-causes/syc-20356194

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Hi @jenniferhunter, How old was your mother when she had the parathyroid surgery? Did she also have osteoporosis?

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@hopeful33250

Hi @jenniferhunter, How old was your mother when she had the parathyroid surgery? Did she also have osteoporosis?

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@hopeful33250 Teresa, my mom had parathyroid surgery 4 years ago at age 85. Yes, she also had osteoporosis and thin bones and the parathyroid problem was pulling calcium out of her bones in spite of prescriptions for hardening bones. They tracked calcium levels for several months before it was bad enough to operate, and she had some cognitive issues because of it that got better after parathyroid surgery. We got her through the surgery, and a week later she fell and broke her pelvis, her foot and her ankle which changed everything and contributed to the disability that she now has. I was there when it happened. I didn't see her feet during the fall, but I suspect that either she twisted her ankle, or the bone fractured in her foot when she stepped on it causing the fall. In time, the foot and pelvis fractures caused her foot to twist after it healed and it got to where she could not straighten it and stand on it because all the tendons shortened. There was surgery for that and the Achillles tendon was lengthened by cutting it and splicing it back together, and a few muscle attachments on the foot were moved. She can't walk well and uses a wheel chair now. We are awaiting the results of a bone density scan from this past week.

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