Virtual RoundsPresentationA Case of Hypercalcemia Heather Taylor November 9, 2010
Hypercalcemia 57 year old Caucasian female Generally healthy
Hypercalcemia Chief Complaint: review lab results (June 30) History of Illness: seen by GP in April c/o bilateral shoulder pain. Recently started exercise program O/E full ROM but weakness rotator cuff muscles & tender supraspinatus. Xrays -> bilateral calcification in rotator cuff Ca+ 2.88 May 5thPTH normal. Repeat calcium normal. Dx rotator cuff tendonitis. Plan: repeat calcium. Exercise. NSAIDS. May 20thcalcium 3.01 PTH normal
Hypercalcemia June 30thPresented at clinic for lab results. c/o “normal aches and pains”, itchy eyes, drippy nose Sent for TSH, PTHrp, ionized calcium, Vit D 1,25 & Vit D 25 July 8th: c/o hx crampy abdominal pain, constipation, nausea, fatigue, skin “feels dry”, headache, irritability, leg weakness & trouble concentrating; sx for 2-3 weeks, thought was dehydrated so took Pedialyte...sx improved. similar episode 4 months ago, lasted only 2 days.
Hypercalcemia Past Medical History: lichen sclerosis. Mild depression Allergies: palm oil -> wheezing Meds:Trazadone 50 mg po HS. No antacids. Calcium 1 gm/day. Vit D 800 IU/day Family History: older sister with lupus. Younger sister with arthritis. 4 sisters & niece with thyroid problems. Father, 2 sisters, daughter with depression. Mother deceased breast cancer age 62. younger sister with early CRC Social History: quit smoking 25 yrs ago. Drinks 1-5 beer &/or wine a day; can take it or leave it. CAGE neg
Hypercalcemia Physical Exam General Appearance: alert, slim 57 yr old female; appears her stated age. No acute distress. BP 112/65 HR 68, regular RR 16 EENT: normal. No enlarged nodes. Thyroid not enlarged. Chest clear CVS: S1S2 normal. No murmurs Abd: soft, nontender. No masses. Neuro: CN II-XII normal. 5+ strength bilateral UE, LE. DTR 2+ Labs: Calcium 3.25 ionized calcium 1.89 TSH, CBC, PTH, CK, lytes, Bun, creatinine Vit D normal
Hypercalcemia Differential Dx: ? Plan: ? Refer to Internal Medicine Pt went to Prince George for 3 wks.
Hypercalcemia • Results when calcium entering circulation exceeds calcium excreted in urine or deposited in bone • Due to: increased bone resorption, increased GI absorption, decreased renal excretion. • Hyperparathyroidism & malignancy make up 90% of cases
Hypercalcemia Causes of increased bone resorption • Primary hyperparathyroidism: (usually not > 3.25) • increased PTH -> increased bone resorption & increased serum calcium • increased calcium absorption in GI tract • 2ndary hyperparathyroidism: often assoc with CKD; low or normal calcium; can increase with prolonged disease 3. Malignancy: hypercalcemia associated with many tumors eg. Bone mets, multiple myeloma PTHrp assoc with nonmetastatic solid tumors 4. Thyrotoxicosis: mild hypercalcemia in 15-20% of pts
Hypercalcemia Causes of increased calcium absorption • High calcium intake alone rarely causes hypercalcemia (elevated serum calcium -> PTH ) • High calcium intake plus reduced urinary excretion -> • CKD: decreased calcium excretion/elevated serum phosphate/decreased calcitriol synthesis • Milk-Alkali syndrome: excess milk or calcium carbonate -> hypercalcemia, metabolic alkalosis & renal insufficiency
Hypercalcemia • Excessive Vit D: increases calcium absorption & bone resorption • 1,25 -> results from: a) excess intake calcitriol eg. tx for hypoparathyroidism, or hypocalcemia/2nd’ary hyperparathyroidism of renal failure. Lasts 1-2 days; tx with salt & fluids, stopping calcitriol. • Increased endogenous production eg pts with lymphoma, chronic granulomatous disorders (sarcoidosis, Wegeners) • high 25OHD from excess Vit D or calcidiol intake lasts longer; more aggressive tx needed
Hypercalcemia Other less common causes of hypercalcemia • Lithium -> increased PTH secretion • Thiazide diuretics -> decreases urinary calcium excretion • Pheochromocytoma -> rare; ?due to concurrent hyperparathyroidism • Adrenal insufficiency • Rhabdomyolysis & diuretic phase of ARF • Theophylline toxicity • Familial hypocalciuric hypercalcemia • Metaphyseal chondrodysplasia: rare form of dwarfism
Hypercalcemia Diagnostic Approach • Clinical & lab evaluation to distinguish between hyperparathyroidism & malignancy • PTH-mediated: 1’ary hyperparathyroidism, familial hyperparathyroid syndromes • Non PTH-mediated: malignancy, Vit D excess, granulomatousdx 1. Repeat sample to confirm hypercalcemia 2. Clinical evaluation, duration of high calcium, presence of sx, FH, & meds may give clues. 3. PTH: frankly elevated or in upper half of normal -> primary hyperparathyroidism 4. PTH < 20 pg/ml: look for other causes. 5. PTHrp & Vit D metabolites
Hypercalcemia Symptoms of hypercalcemia • Polyuria, altered mentation, nausea, vomitting, constipation • Life-threatening -> arrythmia, ++volume depletion due to polyuria Chronic mild hyperparathyroidism • Usually no symptoms • Increased risk osteopenia, renal calculi, nephrocalcinosis
Hypercalcemia Interpretation of serum calcium • Hypercalciumemia due to ionized (free) calcium • 40-45% calcium bound to albumin • Increased protein-binding can cause elevation in serum total calcium but not ionized calcium. Occurs in pts with hyperalbuminemia due to severe dehydration & rarely MM. • Hypoalbuminemia -> normal total calcium, but elevated ionized calcium.
Hypercalcemia Degree of hypercalcemia useful • < 2.75 mmol/L more likely primary hyperparathyroidism • > 3.25 mmol/L more common with malignancy • 10-20% of pts with 1’ary hyperparathyroidism have PTH in upper end of normal
Hypercalcemia Key Points • Know when to check calcium • Know what to look for if elevated • Comprehensive hx can give clues
Hypercalcemia Questions? Thank you!