HYPERCALCEMIAMURTAZA RASHID M.D

Department of Emergency MedicineROYAL COMMISSION HOSPITAL

JUBAIL

A 42 Y/O MAN WITH FEVER, MALAISE, ANOREXIA, WEIGHT LOSS, DIZZINESS, AND INTERMITTENT DRY COUGH SINCE TWO MONTHS.

VISITED NUMEROUS CLINICS IN PAST MONTH BUT STILL UNWELL.

NO SIGNIFICANT PAST MEDICAL HX. NON SMOKER, NON ALCOHOLIC. POORLY INFORMATIVE, BUT COOPERATIVE.

CASE STUDY

P/E B.P: 100/62, R.R : 28, TEMP: 38.7, SAT: 97% THIN, LEAN, ILL APPEARING PATIENT WITH MUSCLE WASTING. HEENT: TEMPORAL MUSCLE WASTING, MILD PALE CONJ, NO NECK RIGIDITY,

NO NECK LYMPH NODES, JVP NORMAL. CHEST: BSE, ↓ PERCUSSION BOTH SIDES, NO AXILLARY NODES, NO RALES

OR WHEEZING. ABDOMEN: SOFT, MILD EPIGASTRIC TENDERNESS, NO SIGNS OF ASCITES,

NO CAPUT MEDUSA, LIVER ABOUT 3-4 FINGERS BCM, NO SPLEEN FELT. EXTREMITIES: MUSCLE WASTING, POWER 4/5 BOTH SIDES, NO

FLAPPING TREMOR OR ASTREXIS. NEUROLOGICAL: 15/15, ALERT, BLUNT AFFECT, LOSS OF COHERENCE,

NO LATERALISING SIGN, PLANTARS MUTE.

CASE STUDY

SOCIAL: WORKING AS A DRIVER WITH A FAMILY, ARRIVED IN KSA BEFORE 4 MONTHS.

IMAGING: CXR: DIFFUSE NODULAR INFILTRATION BILATERALLY, MOSTLY MIDDLE AND LOWER LOBES. NO CAVITY, NO EFFUSION, NO BONE LESIONS. INCREASED BRONCHO-VASCULAR MARKINGS.

LABORATORY: CBC: NOT SIGNIFICANT. CHEMISTRY: ELEVATED AST, AST (3x); Ca : 15 md/dl (4.04mmol) Urine: normal ESR, CRP: Elevated.

NON CONTRAST CHEST CT

BACTERIAL PNEUMONIA P. JIROVECI MILIARY TUBERCULOSIS MERS-CoV NEOPLASTIC MALIGNANCY GRANULOMATOUS Dx VIZ SARCOIDOSIS

DIFFERENTIAL DIAGNOSIS

ELECTROCARDIOGRAM

HYPERCALCEMIA

CALCIUM METABOLISM

PHYSIOLOGY

Ca >10.3 mg/dl or ionized Ca > 5.2 mg/dl with normal albumin level.

DEFINITION

COMMON CAUSES

>90% PRIMARY HYPERPARATHYROIDISM (PPTH) OR MALIGNANCY

PPTH MOST COMMONLY IN AMBULATORY PATIENTS ESP IN ELDERLY WOMEN.

85% PPTH ADENOMA OF SINGLE GLAND.

MALIGNANCY MOST COMMON IN HOSPITALIZED PATIENTS. OSTEOCLAST BONE RESORPTION.

REST OF CAUSES: MILK ALKALI SYNDROME, GRANULOMATOUS, EXCESSIVE INTAKE.

CAUSES

CALCIUM SOURCES

ALGORITHM

CLINICAL PRESENTATION

SERUM Ca OR IONIZED Ca CORRECTED Ca Ca = {Ca} + {0.8× (4.0 – ALBUMIN)}.

≥SERUM PTH IN PPTH >1,25 DH CALCITRIOL IN PPTH,

GRANULOMATOUS, CALCITRIOL OVERDOSE. PHOSPHORUS: ↓HPPTH ; ↑ PAGETS AND VIT D . URINE Ca: ↑ PPTH

LABORATORY TESTING

ELECTROCARDIOGRAM

SHORTENED QT INTERVAL, OSBORNE J WAVES

ELECTROCARDIOGRAM

CAN LEAD TO AV BLOCK, OR DEADLY VT

ACUTE MANAGEMENT SYMPTOMATIC OR Ca > 12 mg/dl

CORRECTION OF HYPOVOLEMIA 0.9% SALINE, MAINTENANCE OF OUTPUT 100-150 ml/hour

LOOP DIURETICS INCREASE Ca EXCRETION.

IV BISPHOSPHONATES ↓ BONE RESORPTION,

TREATMENT

PAMIDRONATE (Ca ≥ 13.5 mg/dl) 60-90 mg infusion over 2- hrs.

EFFECT SEEN WITHIN TWO DAYS AND UPTO TWO WEEKS. DOSE CAN BE REPEATED AFTER SEVEN DAYS.

ZOLEDRONATE MORE POTENT. 4 mg infused over 15 mins.

IV BISPHOSPHONATES

CALCITONIN (4-8 iU/kg): IM OR SC Q6H – Q12H INHIBITS. BONE RESORPTION AND INCREASES EXCRETION.

↓ 1-2 mg/dl in few hours. LESS POTENT, SAFE IN RENAL FAILURE , LESS TOXICITY,

ANALGESIC EFFECT IN BONE METASTASES.

GLUCOCORTICOIDS (20-60 mg/day): PREDNISONE.

HEMATOLOGICAL MALIGNANCIES OR GRANULOMATOUS DX.

GALLIUM NITRATE (100-200 mg/m2/d: POTENT BUT RISK OF NEPHROTOXICITY

OTHER OPTIONS

DIALYSIS Ca > 16 mg/dl. CHF RENAL IMPAIRMENT.

OTHER OPTIONS

FIRST EKG MACHINE