Vet Rec Case Rep: first published as 10.1136/vetreccr-2019-001007 on 4 August 2020. Downloaded from http://vetrecordcasereports.bmj.
com/ on August 8, 2020 at University of Glasgow.
1
Pet Emergency Treatment
Services Ltd, Maidstone, UK
2
Royal (Dick) School of
Veterinary Studies and The
Roslin Institute, University
of Edinburgh, Easter Bush
Veterinary Campus, Roslin,
Midlothian, UK
Correspondence to
Dr Richard J Mellanby;
​richard.​mellanby@e​ d.​ac.u​ k
Received 30 October 2019
Revised 16 June 2020
Accepted 14 July 2020
© British Veterinary Association
2020. No commercial re-­use.
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Published by BMJ.
To cite: Mullany A,
Waddington A, Mellanby RJ.
Vet Rec Case Rep
Published Online First:
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Mullany A, et al. Vet Rec Case Rep 2020;8:e001007. doi:10.1136/vetreccr-2019-001007
COMPANION OR PET ANIMALS
Hypercalcaemia in a dog with lymphoma without
increases in parathyroid hormone, parathyroid
hormone-­related protein and vitamin D
metabolites concentrations
Alex Mullany,1 Abigail Waddington,1 Richard J Mellanby ‍ ‍ 2
SUMMARY
Lymphoma is one of the most common causes of
hypercalcaemia in dogs. Typically, the hypercalcaemic
state is driven by ectopic production of parathyroid
hormone-­related protein by the malignant lymphoma
cells. In this case report, the authors describe the
diagnosis of lymphoma in a dog with hypercalcaemia
which had a plasma parathyroid hormone-­related protein
concentration within the reference range. Furthermore,
circulating concentrations of the two other main
hormones which are known to increase serum calcium
concentrations, namely parathyroid hormone and 1,25
dihydroxyvitamin D, were also below the upper limits
of their respective reference ranges. This case report
highlights that hypercalcaemia is not invariably mediated
by increases in circulating concentrations of parathyroid
hormone-­related protein. In addition, it emphasises
the need to further investigate the pathophysiology of
malignancy-­related hypercalcaemia in dogs.
BACKGROUND
Hypercalcaemia is an important and debilitating
metabolic disturbance which is commonly diag-
nosed in dogs.1 The main causes of hypercalcaemia
in dogs include malignancy, notably lymphoma
and apocrine gland adenocarcinoma of the anal
sac, hypoadrenocorticism, primary hyperpara-
thyroidism and chronic renal failure.2–4 Granulo-
matous diseases and hypervitaminosis D are also
well-­recognised, although less common, causes of
hypercalcaemia.5 6 The presence of hypercalcaemia
can cause significant clinical signs such as poly-
dipsia, polyuria, lethargy and inappetance.1
Since deviations above or below the reference
range can cause significant clinical signs, calcium
concentrations are tightly regulated in healthy
animals.7 The two main hormones which can
increase calcium concentration in healthy animals
are parathyroid hormone (PTH) and the meta-
bolically active vitamin D metabolite 1,25 dihy-
droxyvitamin D3 (1,25(OH)2D3). Dogs are reliant
on the oral consumption of vitamin D since they
are unable to cutaneously produce it. Vitamin D is
metabolised to 25 hydroxyvitamin D (25(OH)D),
which is the metabolite most widely measured to
assess for vitamin D sufficiency, before being metab-
olised in the kidney to 1,25(OH)2D3.7
Veterinary Record Case Reports
In some malignant conditions, hypercalcaemia
may occur due to tumour production of parathy-
roid hormone-­ related protein (PTHrp).8 9 The
effect of PTHrp is very similar to PTH with prin-
cipal sites of action in skeletal and renal tissues
leading to an increase in calcium reabsorption in the
kidney and bone resorption. Both of these effects
have the ultimate effect of increasing serum calcium
concentration which can directly cause highly debil-
itating clinical signs.1 However, even in cases where
PTHrp concentrations are above the reference
range other pathophysiological mechanism(s) may
still be important in causing a hypercalcaemic state.9
Protected by copyright.
In humans, other pathophysiological mecha-
nisms have been reported to cause hypercalcaemia
in patients with a malignancy.10 These include
the local osteolytic bone resorption by tumours
directly involving skeletal tissues and increased
pro-­inflammatory cytokine production which can
directly disturb calcium homeostasis.10 In addition,
ectopic production of 1,25(OH)2D3 by neoplastic
tissue has also been reported.10 In contrast, there
have been few case reports in dogs with a confirmed
malignancy and hypercalcaemia without an increase
in PTH, PTHrp and 1,25(OH)2D3. This case report
describes a dog with hypercalcaemia and histologi-
cally confirmed lymphoma that had a PTH, PTHrp
and 1,25(OH)2D3 concentrations below their
respective upper reference ranges.
CASE PRESENTATION
A 24  kg, five-­
year-­
old, female neutered golden
retriever presented with inappropriate indoor
urination on two occasions and mild polydipsia.
The dog was previously diagnosed with a chronic
enteropathy which was being managed with a
tinned hydrolysed hypoallergenic diet (Hill’s Z/D).
Recently, the owner had received notice of a Hill’s
Z/D diet recall due to concerns that it was exces-
sively supplemented with vitamin D.
INVESTIGATIONS
On clinical examination, no abnormalities were
detected. To further explore potential causes of
the mild polydipsia and the inappropriate urina-
tion, serum biochemistry, haematology and urinal-
ysis were performed. The abnormalities detected
on the serum biochemistry were an increase in
1

Veterinary Record Case Reports
calcium (3.3 mmol/l, ref. range 2.1–3.0 mmol/l), increase in urea
(11.8 mmol/l, ref. range 1.7–9.8 mmol/l), decrease in glucose
(3.6 mmol/l, ref. range 4–8 mmol/l) and an increase in amylase
(1215 U/l, ref. range 500–1000 U/l). Ionised calcium was also
increased (1.66 mmol/l, ref. range 1.25–1.5 nmol/l). No abnor-
malities were detected on haematology. Urinalysis showed
specific gravity (USG) of 1.020, a pH of 6.5 and calcium oxalate
crystals were detected on microscopy. In light of the exposure to
food which may have been excessively fortified with vitamin D,
serum concentrations of 25(OH)D was measured and found to
be high (247 nmol/l, ref. range 70–180 nmol/l). The patient’s diet
was changed to a different batch and the patient was monitored
for the anticipated clinical improvement once the hypervitamin-
osis D and hypercalcaemic states resolved following withdrawal
of the overfortified food.
Three weeks later, the patient presented with mild
anorexia. Repeat serum biochemistry revealed an increase in
urea (21.8 mmol/l, ref. range 2.5–9.6 mmol/l) and creatinine
(288 mmol/l, ref. range 44–159 mmol/l). The serum calcium
concentration had further increased (above 4  mmol/l, ref.
range 2.1–3.0 mmol/l), and ionised calcium had also increased
(1.82 mmol/l, ref. range 1.25–1.5  mmol/l). The patient was
admitted for hospitalisation and administered intravenous fluid
therapy (IVFT) (Hartmans, Aqupharm) at a rate of 4 ml/kg/hour.
Treatment with furosemide was initiated to attempt to increase
excretion of calcium and ranitidine and maropitant were admin-
istered to symptomatically treat the inappetance.
The dramatic worsening of the hypercalcaemic state was
unexpected given the withdrawal of the food which may have
been oversupplemented with vitamin D. Consequently, further
causes of hypercalcaemic were considered and additional diag-
nostic testing was performed. An ultrasound examination of the
abdomen revealed bilateral dilation of the renal pelvises with
subjectively increased corticomedullary contrast but normal
shape and size. A 2.7 cm round defined hypoechoic mass also
noted on the head of the spleen. No other abnormalities were
found. No abnormalities were noted on radiographs of the
thorax. Plasma PTH concentration were suppressed (<10 pg/
ml, ref. range 20–65 pg/ml) and the serum PTHrp concentration
was also low (<0.1 pmol/l, ref. range 0–0.5 pmol/l). The serum
25(OH)D concentration was measured again and was now within
the reference range (119.8 nmol/l, ref. range 17.2–139.9 nmol/l).
The dog’s hypercalcaemic state was treated symptomatically
with 4 mg of intravenous zoledronic acid. Within 24 hours,
the patient showed marked clinical improvement with ionised
calcium returning to within normal limits and the patient began
eating. A mild peripheral lymphadenopathy was noted at this
point and a fine-­ needle aspirate (FNA) was performed for
cytology. The patient remained on intravenous fluids for a further
48 hours until the azotaemia stabilised and the patient was eating
well enough to be managed as an outpatient. Cytology was
suggestive of atypical reactive lymphoid hyperplasia or possible
lymphoma and given the equivocal results, a lymph node biopsy
was planned in order to achieve a definitive diagnosis.
Seven days after being discharged, the patient was read-
mitted due to reoccurrence of the anorexia. On examination,
the patient’s lymph nodes were further increased in size and the
patient was slightly subdued. Repeat haematology and serum
biochemistry was performed which revealed that calcium was
increased again (3.78 mmol/l, ref. range 2.1–3.0 mmol/l). Treat-
ment for hypercalcaemia was resumed with furosemide and
IVFT. The basal cortisol concentration was 159 nmol/l, which
eliminated hypoadrenocortism as the cause of hypercalcaemia.
Serum concentration of 1,25 dihydroxyvitamin D was within
2 Mullany A, et al. Vet Rec Case Rep 2020;8:e001007. doi:10.1136/vetreccr-2019-001007
Vet Rec Case Rep: first published as 10.1136/vetreccr-2019-001007 on 4 August 2020. Downloaded from http://vetrecordcasereports.bmj.com/ on August 8, 2020 at University of Glasgow.
the reference range (272 pmol/l, ref. range 164–523 pmol/l).
Due to poor response to diuretic treatment, a second dose of
zoledronic acid was administered which resulted in normocal-
caemia. Once the patient’s hypercalcaemia had resolved, an
excisional biopsy was performed of a popliteal lymph node and
an oesophageal feeding tube was placed. Histological evaluation
of the lymph node revealed that the lymph node architecture
had been replaced by a proliferating population of round cells
forming sheets within a sparse fibrovascular stroma. Individual
cells had poorly defined borders and a small rim of oeosino-
philic cytoplasm, with nuclei approximately 2–2.5 times the
diameter of a red blood cell. Nuclei were rounded or slightly
indented, with stippled chromatin and small indistinct nucleoli.
Cellular and nuclear polymorphism were mild to moderate and
mitoses were numerous (approximately seven per high-­power
field). Occasional residual aggregates of small lymphocytes are
present. The proliferating round cells extend beyond the capsule
to form sheets within the supporting fibrofatty connective tissue.
The histological diagnosis was lymphoma. Immunohistochem-
istry showed widespread and strong immunolabelling within
the proliferating round cell population for CD3 with only small
islands of cells not labelling for this marker. CD79a and PAX5
labelling was restricted to scattered individualised cells resulting
in a diagnosis of T-­cell lymphoma. The immunostaining char-
acteristics together with the H&E findings indicated that the
lymphoma was classifiable as lymphoblastic T-­cell lymphoma or
possibly a peripheral T-­cell lymphoma due to the intermediate to
Protected by copyright.
slightly larger cell type present.
TREATMENT
The dog was treated with a vincristine, lomustine, predniso-
lone and procarbazine chemotherapy protocol. The lymph-
adenopathy improved postinitiation of treatment and the
hypercalcaemia resolved, reaching a nadir of 2.18 mmol/l (2.1–
3.0 mmol/l). Despite the initial improvement, the dog’s clinical
condition deteriorated 10 weeks postdiagnosis at which point
the dog was euthanased.
DISCUSSION
Lymphoma is an important differential diagnosis of hyper-
calcaemia and is widely considered to be the leading cause of
hypercalcaemia in dogs.2 3 Paraneoplastic hypercalcaemia is a
well-­recognised syndrome in dogs with T-­cell lymphoma.11 12
Depending on the clinical features of the disease, the presence of
hypercalcaemia and the associated typical signs such as polydipsia
and inappetance can be the first signs of the disease. In a high
proportion of cases, dogs with lymphoma and hypercalcaemia
have increased PTHrp concentrations which cause increased
renal calcium reabsorption and resorption of calcium from the
skeleton.8 9 In this case, the PTHrp concentration was within the
reference range highlighting that the hypercalcaemia was likely
to be driven by other pathophysiological mechanism(s).
Increased production of 1,25(OH)2D3 by tumour cells has been
implicated as a cause of lymphoma in both dogs and humans,9 10
but was not considered to be the cause of the hypercalcaemia
in this case given that the 1,25(OH)2D3 concentration was not
increased. This dog had consumed pet food which was subse-
quently recalled due to concerns that it had been oversupple-
mented with vitamin D. The 25(OH)D concentration was above
the reference range defined in previous studies of vitamin D
homeostasis in healthy dogs,13 14 but was well below the concen-
trations observed in earlier outbreaks of hypervitaminosis D due

to consumption of foodstuff oversupplemented with vitamin D.5
In support of this conclusion, the 25(OH)D concentration on a
repeat sample was within the reference range even though the
dog remained hypercalcaemic. Consequently, it was not consid-
ered likely that excessive 1,25(OH)2D3, either endogenously
from the tumour or exogenously from the diet, was the cause of
the hypercalcaemic state.
The dog had a PTH which was below the reference range.
This was considered to be an appropriate physiological response
to the prolonged hypercalcaemic state. This phenomenon is
well recognised in dogs with a previous study reporting that in
a cohort of hypercalcaemic dogs with lymphoma, a high propor-
tion of dogs had an increased PTHrp and a concurrent PTH
concentration, which was below the lower limit of the reference
range.8 As the sample arrived at the diagnostic lab frozen, it is
unlikely that the low PTH was due to sample degradation during
transportation. The low PTH concentrations also confirms that
this case does not have concurrent primary hyperparathyroidism
alongside a lymphoma diagnosis.
The pathophysiological basis of the hypercalcaemia in
this case remains unclear. Since the hypercalcaemia resolved
following treatment of the lymphoma, it is highly likely that the
lymphoma disease process was driving the hypercalcaemic state
in a non-­PTH-­mediated, PTHrp-­mediated and 1,25(OH)2D3-­
mediated manner, alone. Tumour involvement in skeletal tissues
which then secrete paracrine factors that stimulate osteoclast
activity and bone resorption can cause potential hypercal-
caemia.10 This is often postulated to be the mechanism by which
bone metastases or multiple myeloma causes hypercalcaemia.
This seems unlikely to be the cause of the hypercalcaemia in
this case given the haematological nature of the tumour and
the lack of clinical evidence of skeletal disease. A wide range of
cytokines, including interleukin (IL)-1, tumour necrosis factor
(TNF)-α and IL-6 have all being implicated to have the potential
to cause hypercalcaemia in human patients with cancer through
RANKL-­dependent and RANKL-­independent mechanisms.10 It
is plausible that increases in some pro-­inflammatory mediators
might have had a different effect on skeletal tissues and caused
a hypercalcaemic state in this case. Finally, the authors cannot
discount the possibility that laboratory error resulted in an
inaccurate reporting of PTH, PTHrp and vitamin D metabolites
measurements. However, the fact that they were performed in
commercial laboratories using assays which have been widely
reported in the veterinary literature means this outcome is
unlikely.13 15 In addition, 25(OH)D was measured on more
than one occasion with the same clinical interpretation with
one measurement taking place in a laboratory which was certi-
fied proficient by the Vitamin D External Quality Assessment
Scheme (DEQAS), giving further confidence to the validity of
the assessment of the dog’s vitamin D status.
In summary, this case demonstrates that not all cases of
hypercalcaemia associated with lymphoma have an increased
PTHrp concentration. Consequently, this case highlights that
in dogs with hypercalcaemia and a normal PTHrp concentra-
tion, lymphoma cannot be discounted as a differential diagnosis.
This case also showcases the need to further understand the
pathophysiology of malignancy-­related hypercalcaemia since all
cases cannot be explained by the well-­defined mechanisms of
increased PTHrp, PTH and 1,25(OH)2D3 concentrations.
Mullany A, et al. Vet Rec Case Rep 2020;8:e001007. doi:10.1136/vetreccr-2019-001007
Vet Rec Case Rep: first published as 10.1136/vetreccr-2019-001007 on 4 August 2020. Downloaded from http://vetrecordcasereports.bmj.com/ on August 8, 2020 at University of Glasgow.
Veterinary Record Case Reports
Learning points
►► Hypercalcaemia is an important complication of lymphoma.
►► Canine malignancy-­related hypercalcaemia is typically caused
by tumour production of parathyroid hormone-­related protein
(PTHrp).
►► This case demonstrates that a hypercalcaemic dog with a
PTHrp concentration within the reference range can still have
a diagnosis of malignancy-­related hypercalcaemia.
►► It also highlights that malignancy-­related hypercalcaemia
can occur without increases in parathyroid hormone and
1,25 dihydroxyvitamin D3 concentrations alongside a normal
PTHrp concentration.
Contributors  AM and AW managed case and prepared case summary. RJM
advised on case management and drafted manuscript.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  RJM has received consultancy fees and a research grant from
Hill’s Pet Nutrition
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data availability statement  All data relevant to the study are included in the
article.
ORCID iD
Richard J Mellanby http://​orcid.​org/​0000-​0002-​3467-​7007
Protected by copyright.
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3
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4 Mullany A, et al. Vet Rec Case Rep 2020;8:e001007. doi:10.1136/vetreccr-2019-001007