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Hypercalcemia

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Case 56 Y O F with generalized body pain for 1 day Also decreased PO intake Expressive aphasia due to CVA, cannot give further history PMH to de discussed later PE: Vitals stable Moderate respiratory distress Somnolent but arousable Breath sounds only in R chest

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Case, Continued Labs: Chem: 138/3.5/94/33/40/0.5

Misc. Causes Hyperthyroidism Ca rarely >11 Direct action of thyroid hormone to promote bone resorption Vit A Intoxication Requires ingestion of > 10x RDA (5000 IU/d) Also Accutane (acne) and Retin-A (acute promyelocytic leukemia) Adrenal Insufficiency Thiazide Diuretics: in PHPT, sarcoidosis, excessive Ca intake

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Misc. Causes Milk-Alkali syndrome Hypercalcemia, metabolic alkalosis, renal failure First described when milk and Na bicarb were used to treat PUD Now seen with increasing use of Ca bicarb for PUD and osteoporosis Immobilization Spinal cord injury or excessive casting Increased bone resorption Peak Ca in 4 week, can last up to one year

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Management Severe hypercalcemia > 14 mg/dl Unusual in PHPT, unless a secondary mechanism is present Dehydration from nausea, vomiting, diuretics Immobilization Large PO calcium intake Severe acute hypercalcemia usually result of malignancy Should we treat?

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Treatment: 1, 2, 3, Correct Intravascular volume depletion: NS 2-4 lit/d Discontinue diuretics +/_ furoemide Bisphosphonates: first choice in management of severe hypercalcemia caused by osteolytic bone resorption Not in milk-alkali syndrome Ca decreases within 24 h, reaches nadir within 1 week Use half the dose in moderate renal insufficiency (GFR>30) Effect lasts 1 week to several months

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Treatment Calcitonin: inhibits osteoclast function Use with bisphosphonates for more rapid onset of action (a few hours) Ca decreases by 1-2 mg/dl Effect lasts a few days Steroids: PO or IV Consider early in Vit D mediated hypercalcemia, including granulomatous disease and lymphoma

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Treatment

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Follow Up Ca repeated, 18.6 with PTH < 3 PTHrP 55 (15-27) 25-OH-Vit D and 1,25-OH2-Vit D 12,000 Bone survey: lucency in calvarium, b/l femur and humerus Rx with IV hydration and steroids (semi-chemo)