hypercalcaemia (case presentation)
DESCRIPTION
A case of hypercalcaemia with 2 possible aetiologies with a discussion of calcium and bone disordersTRANSCRIPT
![Page 1: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/1.jpg)
Intern Case PresentationMrs EB
![Page 2: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/2.jpg)
Overview• Mrs B, 80yo woman, home alone, I with ADLs• Presents with:
▫ 1/52 vomiting & diarrhoea, fatigue, malaise▫ 5/7 constipation▫ 3-4/7 severe generalised abdominal pain▫ ~20kg weight loss since 4/08!▫ Nil fevers/sweats; nil haematemesis/melaena/PR bleed
• PHx▫ Metastatic breast ca T3, ribs, femur, lungs on
exemestane, monthly zolendronic acid (Zometa)▫ Sick sinus sx (PPM inserted 4/4/08)▫ Parathyroid adenoma▫ Past DVT/PE on warfarin▫ Rx: tamoxifen, warfarin, perindopril, vitamin D,
pantoprazole, bisoprolol, GTN
![Page 3: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/3.jpg)
Further PMHx
•Breast Ca:▫Dx 26 years ago: mastectomy, chemo,
radiotherapy▫Recurrence 5 years ago; lung mets
discovered and resected; commenced on aromatase inhibitor
▫4/08: bony mets ribs 8 & 9, T3, femur Switched from aromatase inhibitor
tamoxifen Commenced on monthly zolendronic acid
(bony mets)
![Page 4: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/4.jpg)
Further PMHx
•Parathyroid adenoma:▫Episode of hypercalcaemia 4/08▫PTH found to be high ?cause▫Sestamibi parathyroid scan: area of avid
sestamibi uptake right lower neck corresponding to 2.0x1.0cm density on SPECT/CT ?parathyroid adenoma
▫Surgery refused at this stage•Sick sinus syndrome:
▫Permanent pacemaker inserted 4/08
![Page 5: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/5.jpg)
Examination Findings• General findings
▫Unwell thin looking elderly lady▫JVP low▫Dry mucous membranes▫BP 110/50, HR 100/regular, SaO2 95% RA,
afebrile• Abdominal exam
▫Generalised tenderness w/o peritonism▫Bowel sounds present
• Chest▫Clear lung fields▫Dual heart sounds no added sounds
![Page 6: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/6.jpg)
Investigations
•FBE: Hb 143/WCC 9.7/PLT 268•UEC: Na 129/K 3.3 Urea 13.4 Creat 92
eGFR 54 (baseline >60)•Ca2+: 3.29; albumin 37; corr ca 3.35;
Phos 0.75; Mg2+ 0.61•CRP 1.4, LFT normal•AXR: multiple fluid-air levels suggestive of
small bowel ileus.•CXR: old right lower zone changes
![Page 7: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/7.jpg)
Diagnosis
•Hypercalcaemia causing secondary ileus and marked volume depletion
•Dx Dilemma: cause = bony mets, parathyroid tumour or both?
![Page 8: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/8.jpg)
Initial Management
•Rehydration: 1L N. Saline/2hrs (ED), 4L N. Saline/24hrs (and continued)
•Not for bisphosphanates as already on monthly zolendronic acid
•Ileus managed conservatively
![Page 9: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/9.jpg)
Further Ix & Mx
• PTH 6/4/08 = 26.3, Sestamibi- right lower neck PTH adenoma; sestamibi-avid metastatic disease right ribs, pleura, hilum ?PTHrP secreting mets
• Endocrinology:▫Dx likely due to combination of met breast ca and
primary parathyroidism▫Recommended surgical referral for r/o adenoma
• However: PTH now = 0.1 (Suppressed by very high calcium?)
• Sestamibi scan for diagnosis of parathyroid lump, surgical opinion to follow
• Therefore diagnosis: Hypercalcaemia secondary to bony metastatic disease.
Date 0145 24/6
0731 24/6
1900 24/6
0950 25/6
26/6
Calcium 3.29 2.84 2.92 2.81 2.57
![Page 10: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/10.jpg)
Hypercalcaemia
![Page 11: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/11.jpg)
The presentationof Hypercalcaemia
can be as vagueand confusingas this patient!
![Page 12: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/12.jpg)
Calcium, Vit D, PTH metabolism
![Page 13: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/13.jpg)
Calcium, Vit D, PTH metabolism
![Page 14: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/14.jpg)
Calcium, Vit D, PTH metabolism
![Page 15: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/15.jpg)
Causes :: Overview• Parathyroid Adenomas• Malignancy• Renal failure• Paget’s Disease• Drugs – thiazides, calcium, lithium…• Endocrine: Hyperthyroidism, addisonism• Genetic – Hypervitaminosis D,
Hypercalcaemic hypocalciuria• Sarcoidosis, Granulomatosis (incl TB)
Account for >90% of cases!
![Page 16: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/16.jpg)
Causes :: When to suspect
•Past history of malignancy- esp bony mets, multiple myeloma
•Endocrine problems•On calcium supplementation•Renal patients•Old people, delirium, confusion of unknown
aetiology•Specific drugs – calcium, lithium, thiazides,
vitamin D etc•Other indicators in HOPC/PHx
![Page 17: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/17.jpg)
Causes :: Malignancy (Poor prognostic factor)
![Page 18: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/18.jpg)
Investigations• Serial Ca, PO4• Correct Ca with albumin!!
▫ (40-Alb)*0.2 + serum Ca = corrected Ca• UEC – renal function (ARF 2°
dehydration/hypercalcaemia, CRF causing hypercalcaemia)
• PTH level, ALP, Vit D• Consider multiple myeloma screen – ESR, serum
electrophoresis, urine BJP etc.• Consider ordering urine calcium – 24 hour urine
calcium collection• High PTH - Hyperparathyroidism: Sestamibi
parathyroid scan• Low PTH - Malignancy: CT chest, abdo, pelvis, bone
scan
![Page 19: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/19.jpg)
Management• REHYDRATE aggressively with normal saline (aim
for 200-300mL/hr initially then urine output 100-150mL/hr)▫ Volume depletion most dangerous complication acutely▫ Na+, H2O administration renal Ca excretion
• Frusemide if overloaded – promotes renal ca excretion
• IV bisphosphanate eg pamidronate if Ca>3• Calcitonin if Ca resistant to intervention• Steroids in granulomatous disease, multiple
myeloma, others• If Ca still doesn’t come down- consider
haemodialysis
![Page 20: Hypercalcaemia (Case Presentation)](https://reader036.vdocuments.net/reader036/viewer/2022070319/55842c60d8b42a79568b4f14/html5/thumbnails/20.jpg)
And of course…•Treat the underlying cause.•Renal failure:
▫ 2° hyperparathyroidism (high PTH) Calcimimetics – cinacalcet Vit D analogues (not increasing Ca) – paracalcitriol
▫ 3° hyperparathyroidism (autonomic PTH) Surgical intervention
•Parathyroid nodule/tumour: surgical intervention•Granulomatous disease: steroids•Drugs: cease offending drug•Treat endocrine conditions