1. CASE 2 49 yo man HIV+ since 1993 CD4 Nadir 120/7% Smoker of 45 pack years

2. CASE 2 DATEREGIMENCD4Viral Load 1994AZT200------------- 1995AZT/ddI210------------- 1996AZT/3TC/SQV220------------- 1997-04d4T/3TC/NFV/NVP240<50 2004-12AZT/3TC/ABC/NVP270<50 2012ABC/3TC/NVP/RGV330<40 Antiviral History

3. CASE 2 2012 Depression x yrs Fatigue x yrs Arthralgia/Bone pain

4. CASE 2 DATECaIon. Ca (1.15-1.35) P04iPTH (1.3-8.2) VIT D 25(0-200) 1,25(39-193) Albumin TSH 05/122.79------0.6 7 ------ 49 06/122.871.560.7 2 1.670/33------1.22

5. CASE 2 No family history of endocrine abnormalities No obvious cancer No ingestion of meds known to cause high calcium No calcium supplements, vitamins, herbal remedies, OTC’s or calcium carbonate containing products

6. CASE 2 June 2012 Of note, drinks 4L of milk daily!!!! On Ranitidine for GERD TOLD TO STOP MILK

7. CASE 2 DATECaIon. Ca (1.15-1.35) P04iPTH (1.3-8.2) 06/122.871.560.721.6 07/122.671.500.64---------

8. CASE 2 Felt much less tired with decreased arthralgia/bone pain when milk consumption eliminated

9. CASE 2 DATECaIon. Ca (1.15-1.35) P04iPTH (1.3-8.2) 07/122.671.500.64--------- 08/122.781.530.571.9

10. CASE 2 Further Workup Serum/urine immunelectrophoresis – normal CT Chest/Abdo – Normal

11. CASE 2 Further Workup U/S Thyroid – Small nodule – No change in size with 3mos f/u 24 hr urine for calcium – Elevated urinary calcium 8.6 mmole/l (1.2-6.2)

12. CASE 2 Diagnosis ?mild primary hyperparathyroidism exacerbated by excessive milk consumption