13year old female presented with 3 weeks h/o pain right knee and right elbow, vomitting and constipation..She had h/o menorrhagia for which gynaec doctor gave ocps 1 month back. o/e pallor + ln - chest no added sounds,no murmurs abdomen soft cns-wnl x-ray were taken which is posted below s.calcium-12.6 s.phosphate-2.4 iPTH<1 rft-30/0.6 serum electrolytes-sodium 137 potassium-4.6 cbc-8500 ure-pus cells 6-8 serum ace- normal serum ferritin-350 ldh-368 ALP-128

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Its a case of hyperparathyroidism.

Pseudohyperparathyroidism

rule out hashimotothyroiditis hypothyroidism autoimmune type

Tsh is normal..no palpable thyroid swelling
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Hyperparathyroidism

Praaneolastic syndrome causing pseudohypoparathyrodism

Sir multiple myeloma is usual in old age people.. can we expect this 13yr old male @ sabesan ramachandran??

Hyperparathyroidism?? Please get sr.pth, may need excision of parathyroid if required..

Sir,intact PTH is very low...less than 1ng/l
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Hyperparathyroidism

Very low PTH..
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Pseudohyperparathyroidism xray shows punched out lesions

Thank you everyone for the input.. Final diagnosis came today after BMT and flow cytometry.. It's a case of B cell Acute Lymphoblastic Leukaemia

Wat abt the peripheral smear ???
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