Date post: | 13-Jan-2017 |
Category: |
Documents |
Upload: | meducationdotnet |
View: | 345 times |
Download: | 0 times |
Hypercalcaemia
Laura Wills
Case Study49 ♂
PC- presented to GP about rash on face & snoring
Investigations revealed hypercalcaemia – 3.2mmol/LCame to A&E at HRI
Clerking in AAU3-4 month history of abdominal discomfort
Elbow pain
2-3 month history of ↑ fatigue
Polydipsia & ↑ fluid intake
Negative findingsNo change in moodNo excessive dietary calciumNo unintentional weight lossNo change in appetiteNo feverNo night sweatsNo loin-groin colicky painNo PR bleeding, haematuria, haemoptysisNo chest pain or palpitationsNo SOBNo vomiting & nauseaNo urinary symptomsNo bowel symptoms
PMH – nilDrugs – nilAllergies – nil
SH – non smoker alcohol – 5 units a week lives with wife & two children very active (runner), good diet PHD in engineering – works at
Kimberley Clarke
FH – dad died of multiple myeloma age 62
ExaminationGeneral – comfortable at rest alert & orientated observations stable no signs of dehydration no signs of anaemia
• Chest - NAD
• HS – I + II + 0
• Abdomen – NAD
• Neurological – NAD
• Elbows – no bony tenderness not red, hot, swollen FROM pain on wrist extension
Differentials1. Primary hyperthyroidism
2. Myeloma3. Bone metastases4. Dehydration5. Inflammatory disease6. Thyrotoxicosis
7. Famillial hypocalciuric hypercalcaemia
InvestigationsFBCHb – 15.3WCC – 6.4Plts – 216RCC – 4.67Hct – 0.445MCV – 95.3MCH – 32.8RDW – 12.4
Neu – 3.09Lym – 2.69Mon – 0.49Eos – 0.15Bas – 0.02PV – 1.64
BCPNa – 140K – 4.6Cl – 107Bicarb – 27Urea – 6.5Creatinine – 96
Ca – 3.31 ↑Adj Ca – 3.26 ↑Ph – 0.64 ↓Bil – 27 ↑
AP – 139ALT – 60 ↑TP – 73Al – 46
TSH - normalAmylase – normalPSA – normalCoeliac screen –
negativePTH – 403 ↑
ECG – NADCXR – NADAbdominal USS – NAD
Management
FluidsBisphosphonatesTreat cause
The role of calciumFormation & maintenance of bones & teethRole in blood clottingHormone releaseMuscle contractionNerve & brain functionEnzymatic reactions
The importance of vitamin DEssential for calcium absorption in the
small intestine
Cholesterol
Cholecalciferol
Calcidiol
Calcitrol
Skin
Liver
Kidney & peripherally
Dietary calcium
Calcium levels
2.2-2.6 mmol/LAdjusted Calcium levels
(40-albumin) x 0.02 + albumin
Hypercalcaemia“The presence in the blood of an abnormally high
concentration of calcium” Oxford concise medical dictionary 2007
Mild hypercalcaemia = 2.6 – 2.9 mmol/LModerate hypercalcaemia = 3.0 – 3.4 mmol/LSevere hypercalcaemia = greater than 3.4 mmol/L
Symptoms
Bone painRenal stonesAbdominal pain Mood changes
VomitingConstipationMuscle twitching &
weaknessPolyuria & polydipsiaAnorexia & weight lossLethargy & fatigueConfusionPyrexiaECG changes
“Bones, stones, groans & moans”
ECG changes in hypercalcaemia – short QT intervals - J waves - widening T waves
Aetiology1. Primary hyperparathyroidism
2. Malignancy
•Adrenal gland failure•Milk/alkali syndrome•Dehydration•Iatrogenic•Thyrotoxicosis•Granulomatous disease•Chronic renal failure
•Vitamin D excess•Famillial benign hypocalciuric hypercalcaemia•Paget’s disease•Immobilisation•Phaeochromocytoma•Cuffed specimen
↑ PTH release – primary parathyroidism, paraneoplastic syndrome, chronic renal failure
↑ bone breakdown – Paget’s, Malignancy, Thyrotoxicosis, Immobilization
↑ Ca2+ ingestion – milk-alkali syndrome
Iatrogenic – vitamin D, lithium, thiazide diuretics, cuffed sample
Increased absorption – adrenal gland failure
Ectopic production of calcitrol – granulomatous disease
↓ blood volume - dehydration
Hypercalcaemia
Albumin raised
Albumin normal or low
Urea raised
Urea normal
Phosphate low or normal
Phosphate raised or normal
Dehydration
Cuffed specimen
Urea normal
Primary or tertiary hyperparathyroidism
Alk Phos normal
Alk Phos raised
Bone metsSarcoidosisThyrotoxicosis
MyelomaVitamin D excessSarcoidosisMilk alkali syndrome
ComplicationsRenal –Nephrocalcinosis Renal failure Renal stonesGI - Peptic ulcer disease PancreatitisNeuro - Corneal calcification Confusion, dementia & comaCardiac – Arrhythmia Cardiac failureMSK - Osteoporosis & fractures
ManagementUrgent treatment if calcium
> 3.5mmol/L↓ consciousness or confusionHypotensionSevere dehydration causing pre-renal failure
IV fluidsDiureticsIV bisphosphonatesTreat the cause
Primary hyperparathyroidismEpidemiology
3rd most common endocrine disorder♂:♀ = 1:3Incidence – 25-30/ 100,000Prevalence – 3/1000↑ post menopausal women
Symptoms70-80% asymptomaticAs per hypercalcaemia
AetiologySporadic single parathyroid adenoma – 75-
85%Parathyroid hyperplasiaMultiple adenomasParathyroid carcinomaMEN type 1 & 2AFamilial isolated hyperparathyroidism
DiagnosisPTH ↑Ca 2+ ↑Ph ↓
3hr Ca2+ infusion
Parathyroid imaging – nuclear medicineBiopsy
DEXA scanRenal USS/XR
Treatment
Mild asymptomatic – monitor creat & Ca2+ every 6
months DEXA scan annually avoid dehydration avoid thiazides moderate Ca2+ intakeSurgical – parathyroidectomy
Medical – HRT & raloxifene bisphosphonates cinacalcet
Thank you for listening
Any Questions?