hyper calc emi a by a student
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Hypercalcemia
Ayesha Shaikh
Emory Family MedicineResidency Program
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Introduction
62 years old Nepali female
Cc: Hypertension, indigestion and fatigue
since past many years.
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HPI
1- Hypertension for 10 years , treated with Amlodipine 5 mg inNepal. CXR and blood tests normal at the time of immigration1 month ago. Denies
2- Epigastric abdominal pains since past many years, nonradiating, dull, 4/10, unrelated to the type or timing of foodingestion. Denies nausea, vomiting, diarrhea, constipation.
3- Fatigue for many years. No change in weight, mood orlimitations in daily activity. Denies depressive symptoms.
One prior FPC visit at Dunwoody Clinics for Medicines refill andnecessary labs ordered.
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PMH: Hypertension, no prior hospitalizations
PSH: noneSH: recent immigrant, lives with family
consisting of children and grand children.Good social support system. Daily chores.
Denies smoke or alcohol.ROS: Irritable mood,
Meds: Amlodipine 5 mg
No OTC medicine use
NKDA
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Physical exam
Petit elderly female, no acute distress
Vitals: Height: 5 1 Weight: 100 lbs BMI:20
T: 98.6 P: 61 BP: 154/98 RR: 12Chest
CVS
Abd: normal inspection, palpation, percussionand auscultation
Neuro: Cranial nerves intact, no motor orsensory deficit. Gait normal, reflexes 2+
ENT: Non palpable thyroid gland
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Labs and tests
CBC: normal
BMP: Na: 141 K 4.3,
Bun/creat: 10/0.80Glucose: 95
Calcium: 11.0
albumin: 4.6
Chloride: 107
CO2 21
LFT: WNL
TSH: 0.86
Lipid profile: T.Chol 186
TG 87
LDL 117
HDL 52
Urine Microalbumin/cr 0.2/30= 7
EKG
Previous labs!
Calcium 10.9
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Assessment and Plan
Hypertension: Amlodipine 5 mg
Hypercalcemia: Fup labs PTH
Gastritis: Pepcid
Backache: Lumbar spine X ray
Health maintenance: Flu vaccine andplan RPE visit.
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Test results
PTH: 127 (ref 10-65 pg/ml)
Lumber DJD
Parathyroid scan: Right lower Parathyroidadenoma
Follow up: Blood pressures > 150/90 mmhg,
increased amlodipine dose and added HCTZlater
Endocrinology referral for primaryhyperparathyroidsism
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Endocrinology workup
Exclude underlying secondaryhyperparathyroidism, since low vitamin
D levels very common in mountains ofHimalayas.
25 hydroxyVitaminD levels =10 (30-80)
Vitamin D replacement: 50,000 units/week for 8 weeks. Recheck calcium
and Vit D levels thereafter
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Hypercalcemia
Introduction: 1/500, incidental finding The skeleton contains 98 percent of total body
calcium; the remaining 2 percent circulates
throughout the bodyOne half of circulating calcium is free (ionized)
calcium, the only form that has physiologic effects. The remainder is bound to albumin, globulin, and
other inorganic molecules Corrected calcium = (4.0 mg/dl - [plasma albumin]) X
0.8 + [serum calcium]
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Defination
Normal serum calcium levels are 8 to 10mg/dL (2.0 to 2.5 mmol/L)
Normal ionized calcium levels are 4 to 5.6mg /dL (1 to 1.4 mmol per L)
Hypercalcemia is defined as total serum
calcium > 10.2 mg/dl(>2.5 m mol/L ) or
ionized serum calcium > 5.6 mg/dl ( >1.4 mmol/L )
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Defination
Severe hypercalemia is defined as total serumcalcium > 14 mg/dl (> 3.5 mmol/L)
Hypercalcemic crises is present when severeneurological symptoms orcardiac arrhythmiasare present in a patient with a serum calcium > 14
mg/dl (> 3.5 mmol/L) or when the serum calcium is >16 mg/dl (> 4 mmol/L)
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Hormone Effect on bones Effect on gut Effect on
kidneys
Parathyroid
hormone
increase Ca++,
decrease PO4
levels in blood
Supports
osteoclast
resorption
Indirect effects
via increase
calcitriol from 1-
hydroxylation
Supports Ca++
resorption and
PO4 excretion,
activates 1-
hydroxylation
Calcitriol
(vitamin D)
Ca++, PO4
levels increases
in blood
No direct effects
Supports
osteoblasts
Increases Ca++
and PO4
absorption
No direct effects
Calcitonincauses Ca++,
PO4 levels
decrease in
blood when
hypercalcemia is
present
Inhibitsosteoclast
resorption
No direct effects Promotes Ca++and PO4
excretion
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Pathophysiology
Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D3 (calcitriol), and calcitonincontrol calcium homeostasis in the body
Hypercalcemia is caused by Increased boneresorption, increased gastrointestinal absorptionof calcium, and decreased renal excretion ofcalcium
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Pathophysiology
Calcitonin Inhibits osteoclast resorption ,
promotes Ca++ and PO4 excretion
PTH-related peptide (PTHrP) binds the PTH
receptor and mimics the biologic effects of
PTH on bones and the kidneys
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Clinical manifestations
Hypercalcemia leads to hyperpolarization of
cell membranes
Patients with levels of calcium between 10.5and 12 mg /dl can be asymptomatic. When
the serum calcium level rises above this
stage, multisystem manifestations become
apparent
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Evaluation
Evaluation of a patient with hypercalcemia
should include a careful history and
physical examination focusing on clinicalmanifestations of hypercalcemia, risk factors
for malignancy, causative medications, and
a family history of hypercalcemia-
associated conditions
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Evaluation
Primary hyperparathyroidism : PTH
MALIGNANCY :
1.solid tumors(humoral hypercalcemia):PTHrP ,PTH
2.Multiple myeloma and breast cancer(osteolytichypercalcemia ) :
alkaline phosphatase ,PTH
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TREATMENT
Clinical indications for surgery in patients withprimary hyperparathyroidism
Significant symptoms of hypercalcemia
Nephrolithiasis
Decreased bone mass
Serum Calcium > 12 mg/dl
Age< 50 yearsInfeasibility of longterm follow up
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Pharmacologic options
Normal Saline 2-4 L IV daily for 1-3 days
Enhances filtration and excretion of CA++.
Indication: Ca > 14 mg/dl, moderate Calciumwith symptoms
Caution: may exacerbate heart failure in
elderly patients. Lowers Calcium by 1-3 mg/dl
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Pharmacologic options
Furosemide 10-20 mg IV as necessary
Inhibits calcium resorption in distal renal
tubule.Indication: following aggressive
hydration
Caution: hypokalemia, dehydration ifused before intravascular volume isrestored
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Pharmacologic options
Bisphosphonates
Pamidronate
Zoledronic acid
Inhibits osteoclast action and bone
resporption
Indication: hypercalcemia of malignancy
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Treatment
Calcitonin :
inhibition bone resorption and increases renal calcium excretion
4 to 8 IU per kg IM or SQ every 6 hours for 24 hours
Plicamycin (Mitharmycin) :
decreases bone resorption25 mcg per kg per day IV over 6 hours for 3 to 8 doses
Gallium nitrate :
inhibition bone resorption
100 to 200 mg per m2 IV over 24 hours for 5 days
Glucocorticoids :
Inhibits vitamin D conversionto calcitriol
Hydrocortisone, 200 mg IV daily for 3 days
Hemodialysis :
used in patients with renal failure
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Medical management of
primary
hyperparathyroidism medical therapy with drugs have not been shown to
affect the eventual outcome
estrogens (premarin 1.25mg/day) preserve bonemass in post-menopausal females
well-hydrated by drinking 2 - 3 litres of fluid, and 8 -10 g of salt daily
dietary restriction of calcium is not necessary ,thiazide diuretics must not be used
oral phosphate should only be used if symptomatichypercalcemia cannot be corrected surgically
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Medical management of
hypercalcemia in cancer
patients
2 - 3 litres per day + 8 - 10g of salt/day
Pamridonate can be used prn every few weeks tokeep the serum calcium in the normal range
Prednisone (20 - 50 mg bid) is only useful in certain
malignancies eg. multiple myeloma and certain
lymphomas
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Treatment
Medical management of other disorders :
--prednisone and low-calcium diet ( < 400 mg/day )
Medical management of hypercalcemia in
sarcoidosis :
--a low dose of prednisone (10 - 20 mg/day) is usually
adequate
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References
Carroll M, Schade D. A Practical
Approach to Hypercalcemia. American
Family Physician. May 1, 2003.Taniegra E. Hyperparathyroidism.
American Family Physician. January 15,
2004.