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BACKGROUNDHypercalcaemia is a common cause for presentation to the medical take with a wide differential diagnosis. Identifying the aetiology can be challenging and requires understanding of the complex conditions that present with this electrolyte abnormality. When relying on pattern recognition or 'non-analytic reasoning' this can lead to further challenge and even play a role in diagnostic error. We present here, the case of a patient with hypercalcaemia, raised serum protein and normal albumin, and highlight a number of learning points for the hospital physician. CASE PRESENTATIONA 53-year-old Afro-Caribbean woman presented to casualty with vomiting and a 2-week history of constipation. Over the previous month she had developed an itchy rash on her back. A history of lethargy, hair loss and episodes of itchy eyes over the past 6 months was also elicited. Loss of weight and low mood were noted, although the patient attributed this to the recent death of a relative. Medical history included hypertension, diabetes mellitus, cerebrovascular disease and Raynaud's disease.Physical examination revealed cervical lymphadenopathy and hepatomegaly. The patient had a nodular rash with crops of lesions over the upper back without any alteration in pigmentation ( fi gure 1 ). Per rectal examination did not reveal an obstructive cause for her constipation. INVESTIGATIONSChest radiograph was normal, and abdominal radiograph revealed faecal loading. The most striking biochemical abnormality on admission was an elevated corrected Unusual association of diseases/symptoms Hypergammaglobulinemia, normal serum albumin and hypercalcaemia: a case of systemic sarcoidosis with initial diagnostic confusion

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