8/2 Morning Report w/ Kat Iwata: Hypercalcemia

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!

-PTH

-PTHrP

-1,25 Vit D for granulomatous process (sarcoid)

-25 Vit D level for vitamin D toxicity

-SPEP/UPEP

DDx

-Malignancy

-Multiple Myeloma

-Milk Alkali Syndrome

-Hyperparathyroidism

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).

7/15 Morning Report with Alice Zhang and Dr. Sanders

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)

Hyperparathyroidism

Vit D Toxicity

Renal Failure

Multiple Myeloma

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

Management

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.