An elderly gentleman with a pmh of CAD who presented with 6 months of progressive confusion and global weakness admitted for hypercalcemia also found to have a new anemia and AKI.
Know workup of hypercalcemia – think about malignancy in hospitalized patients!
-1,25 Vit D for granulomatous process (sarcoid)
-25 Vit D level for vitamin D toxicity
-Milk Alkali Syndrome
Acute treatment of hypercalcemia -> fluids, fluids, fluids — In this case aggressive fluid resuscitation threw this patient into pulmonary edema. Remember that pamidronate takes 2-3 days to work.
Update: SPEP came back with M spike and increased lamda light chains highly suggestive of multiple myeloma. He is now out of the ICU and s/p bone barrow biopsy to seal the diagnosis. (To diagnose multiple myeloma you need a bone marrow biopsy looking for > 10% clonal plasma cells).
An elderly man with a history Alzheimer’s and UC s/p colectomy presents from a nursing facility with nausea and vomiting for 1 week. Found to have a calcium level of 18.
Know the DDx of Hypercalcemia
Hypercalcemia of malignancy (mets, PTHrp)
Vit D Toxicity
Milk Alkali Syndrome
Granulomatous Disease (1,25 mediated) – TB, Sarcoid
*Hyperthyroidism can also cause Hyper Ca via increased osteoclastic activity
In this case, the patient was on high doses of calcium supplements and had developed milk-alkali syndrome with a metabolic alkalosis.
EKG Findings of Hypercalcemia -> Shortened QT, Osborne Waves
Treatment: Fluids, fluids, fluids —- see how the calcium level is responding before giving Lasix;
Think about the mechanism that is causing the hypercalcemia – if due to increased osteoclastic activity give a bisphosphonate – this will take 1-2 days to work
Calcitonin: If not responding to fluids – calcitonin works quickly
This patient’s calcium level corrected over the course of a couple days with a total of 6-7 L of fluid and 2 doses of calcitonin.