No Stones, Some Groans, and Psychiatric Overtones with “Non-specific” Splenomegaly

Hypercalcemia is a potentially life-threatening electrolyte imbalance that is commonly caused by hyperparathyroidism, supplement or medication use, and/or malignancy. Splenomegaly is commonly a non-specific finding, but in the setting of hypercalcemia, may provide diagnostic insight into the underlying pathology and warrant further evaluation. A 70-year-old man presented from his outpatient provider with serum calcium > 15 mg/dL with complaints of one-month fatigue, weakness, poor oral intake, 10 lbs. unintentional weight loss, and periodic confusion noted by his wife. He received an extensive inpatient workup which was non-diagnostic. Splenomegaly was observed on radiographic imaging and reported as “nonspecific”. Following discharge, denosumab was required to manage the hypercalcemia. Eventually, a diagnosis of primary splenic lymphoma was made months later. Laparoscopic splenectomy was planned but was advanced to an open laparotomy intraoperatively due to the rapid growth of the neoplasm. Early and close investigation of the spleen is warranted when splenomegaly presents in the setting of hypercalcemia and, as in this case, may prevent significant therapeutic burden.