Case 1 53F presents to ED with dysuria

PMHx: HTN, Hyperlipidemia,

UTI is diagnosed and oral Abx script given

Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L

On further history the patient states she has no symptoms and has been otherwise well.

Management? Disposition?

Case 2 70M with known Lung CA, presents with

acute psychosis and Ca= 3.4 mmol/L

Management?

Hypercalcemia

Lab RoundsSultana Qureshi, PGY-2August 3, 2006

Calcium Metabolism

Hormone Effect on bones Effect on gut Effect on kidneys

Parathyroid hormone Ca++, PO4 levels in blood

Supports osteoclast resorption

Increases absorption via Vit D

Supports Ca++ resorption and PO4 excretion, activates 1-hydroxylation

Vit D Ca++, PO4 levels in blood

- Ca++ and PO4

absorption -

Calcitonin Ca++, PO4 levels in blood

when hypercalcemia is present

Inhibits osteoclast resorption

- Promotes Ca++ and PO4 excretion

Definition

Total Corrected Serum Ca2+ >2.62 mmol/L

OR Ionized Ca2+ > 1.35 mmol/L

Corrected = measured Ca2+ + 0.02 (40-albumin)

Or for every ↓5 of albumin, add 0.1 to serum Ca

Symptoms“Bones, Stones, Groans, Moans”

General Weakness, malaise,

dehydration Skeletal (Bones)

Bone pain Fractures/Deformities

GI (Groans) Constipation Abdo pain Anorexia & W.L., NV PUD, pancreatitis

Cardiovascular Dysrhythmias ECG changes HTN, vascular calcification

Renal (Stones) Nephrolithiasis Polyuria, polydipsia, nocturia Nephrogenic DI Renal failure

Neurologic Hypotonia, Hyporefelxia, ataxia Myopathy Paresis Altered LOC/Coma

Symptoms (cont’d)“Bones, Stones, Groans, Moans”

Psychiatric (Moans)

> 3mmol/L Increased alertness Anxiety/Depression Cognitive Dysfunction Organic Brain Syndromes

> 4mmol/L Psychosis

ECG

Changes:

-shortening of QT

-prolongation of PR

-ST depressions

U- waves

Severe:

-bradyarrythmias

-BBB and high AV block

-potentiates Digoxin effects

-Cardiac Arrest

Causes

90% of cases due to Primary Hyperparathyroidism (30-50%)

25-75/100 000 (US) mcc Parathyroid adenoma Usually mild hyperCa High PTH

Malignancy (40%) 20-30% of Cancer patients Poor prognosis – 1 yr survival = 10-30% Lung/Breast/Kidney/Myeloma/Leukemia More likely to be encountered in ED Low PTH 2 mechanisms: PTHrP or osteolytic

Other common causes

Iatrogenic/DrugsThiazidesLithiumHypervitaminosis A & D

Granulomatous DiseaseSarcoidosisTuberculosis

Other less common causes:

Parathyroid hormone-related Sporadic, familial, associated with multiple endocrine neoplasia I or II Tertiary hyperparathyroidism Associated with chronic renal failure or vitamin D deficiency Vitamin D-related Vitamin D intoxication Usually 25-hydroxyvitamin D2 in over-the-counter supplements Hodgkin's lymphoma Genetic disorders Familial hypocalciuric hypercalcemia: mutated calcium-sensing receptor

Medications Milk-alkali syndrome (from calcium antacids) Other endocrine disorders Hyperthyroidism Adrenal insufficiency Acromegaly Pheochromocytoma Other Immobilization, with high bone turnover (e.g., Paget's disease, bedridden child) Recovery phase of rhabdomyolysis

Who needs immediate ED treatment?

Ca > 3.5 mmol/L

Ca > 3 mmol/L with symptoms

Management

Four Goals

1) Correct Hypovolemia

2) Increase renal calcium excretion

3) Reduce osteoclastic activity

4) Treat primary disorder

Management

1) Correct Hypovolemia Decreases Ca by 0.4 - 0.6 Increases GFR & Na load to kidneys, thus Ca excretion Various recommendations

NS IV @ 200-300cc/hr. Usually require 2-4L per day X 1-3 days. Aim for U/O of 200 cc/hr

Caution with elderly, poor LV function Also, correct co-existing electrolyte abnormalities

Management

2) Increase renal calcium excretionCorrecting HypovolemiaLasix 10-40 mg IV q6-8h Dialysis in patients with renal failure

Management 3) Reduce osteoclastic activity

Bisphosphonates Pamidronate 60-90 mg IV over 4 hours Max effect in 72 hours More effective in hyperCa of malignancy

Calcitonin In severe cases, 4 un/kg SQ q6h Starts working with a few hours

Glucocorticoids In Vit D mediated hyperCa (Vit D intoxication, hematologic

malignancies, Granulomatous disease) Hydrocortisone 200-300mg IV qd X 3 days

Mythramycin, Gallium Nitrate, IV phosphate – no longer used

Case 1 53F presents to ED with dysuria

PMHx: HTN, Hyperlipidemia,

UTI is diagnosed and oral Abx script given

Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L

On further history the patient states she has no symptoms and has been otherwise well.

Management?

Case 2 70M with known Lung CA, presents with

acute psychosis and Ca= 3.4 mmol/L

The End