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Belal Firwana

on 7 October 2017

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Transcript of Hypercalcemia

Chairman's Report
By: Belal Firwana

Hospital Course
Unfinished Issues !
Differential Diagnosis
Dx Algorithm
Lab Tests
Case Presentation
A 67-year-old, Caucasian male presented as a direct admit from Rheumatology clinic because of critical lab value of calcium of 13.7.

He did not feel sick, but reported having less energy, fatigued, not getting up really much, no appetite, was not eating okay since Christmas.
Treated with:
IV fluids
Calcitonin x3 days
One dose of Prednisone 60mg
(PPx for contrast allergy)
PTHrP does not rule-out malignancy related hypercalcemia
? bone invasion
1. Inclusion body myositis:
Stopped prednisone last year
On methotrexate since then
Currently not on any medications.
2. Colon cancer: s/p surgical resection in 1988; had x2
colonoscopy - wnl; pending in couple of months.
3. Hypertension
4. Hyperlipidemia
5. Coronary artery disease
6. Bilateral hernia repair
7. Right renal artery stent placed in 2001
8. Severe left hydroureteronephrosis and a large 1.8 cm left distal
ureteral calculus. Lithotripsy & left ureteral stent placement
General: was fatigued & weak; denied headache, dizziness, tingling, numbness, no confusion.

Abdomen: Has bloating; loose stools for 2 mo, w/ no blood or mucus noted. Denies any abdominal pain.

Genetourinary: denied burning micturition, change in color of urine or incontinence.

Musculoskeletal: He also reports to have restless legs since 3 weeks & is taking ibuprofen at night mostly; prescribed on Requip but has not had his first dose yet.
Family Hx
Social Hx
Father: Diabetes type II
Mother: Hypertension.
Sister: breast cancer and colon cancer.
Lives in Booneville
Disabled due to inclusion body myositis
Smoking: quit in 1984.
EtOH: occasionally
Illicit drugs: none
Physical Exam:
GENERAL: Patient was lying in bed, in no acute distress.

HEENT: Normocephalic atraumatic. Oral mucosa moist. Tongue in midline. No thyroid enlargement. No cervical lymphadenopathy. No JVD noted.

RESP: Clear to auscultation bilaterally.

CV: S1, S2 heard. No murmurs, rubs, or gallops heard.

GI: Soft, nondistended. Tenderness noted in the left upper and middle quadrant. Mass palpable in the left upper quadrant. Splenic notch cannot be palpable. Could be mostly his left enlarged kidney because of hydronephrosis. No CVA tenderness noted or any suprapubic fullness noted.

NEURO: Alert, oriented x3. Cranial nerves II to XII intact.

PSYCHIATRIC: Appropriate mood and judgment.
T 35.7
HR 74
RR 16
BP 140/75
Na+ 137
K+ 4.4
Cl- 106
CO2 25
GLU 78
BUN 51 (H)
Creat 2.70 (H)
GFR 23.69 (L)
Ca 13.7 (C)
Alk Ph 65
AST 10
ALT 17
T Bili 0.4
T Pr 6.3 (L)
Alb 3.5
WBC 7.2
Hgb 12.6
HCT 37.4
MCV 87.9
PLT 260
UA Sp Gr 1.020
UA pH 6.0
UA Glucose Negative
UA Ketones Negative
UA Bili Negative
UA Blood Small
UA Leuk Negative
UA Nitrite Negative
UA Protein 30
Admission Labs
Other Labs
ACE level
Vit D 25-OH
Vit D 1,25-OH
Vit A
24-hr U Ca
Gamma-globulin approaching lower limits; Beta-globulin slightly decreased
Essentially normal urine protein electrophoresis.
10.4 (L)
3.5 (N)
16 (L; 30-80)
33 (N; 15-75)
0.24 (L)
<2.0 (L)
64 unit/L
290 (H)
Kidney Ultrasound
Left kidney measures 17.5 x 9.3 x 7.7 cm. Marked left kidney hydronephrosis with dilatation of the proximal two thirds of the ureter up to 4 cm is again seen.
The right kidney measure 11.6 x 6.1 x 5.9 cm. No evidence of right-sided hydronephrosis is seen. There is mild thinning of the right renal cortex measuring approximately 0.8 cm.
Right ureteral jet is present. The left ureteral jet is not seen.
CT - Chest / Abdomen / Pelvis
Chest: Left upper lobe parenchymal band along the fissure and superior left lower lobe 9 mm nodular density (2/27) are similar in appearance to the prior study on 12/8/2008. Small bilateral pleural effusions. Right lower lobe calcified granuloma. Right lower lobe linear band of airspace consolidation and right middle lobe and left lower lobe parenchymal bands also appear similar to the prior study on 12/8/2008. Sclerotic calcification of the thoracic aorta and coronary arteries. No axillary or mediastinal lymphadenopathy identified. Evaluation of mediastinal and hilar structures is limited on this noncontrasted study. Calcified mediastinal nodes again noted.

Abdomen/pelvis: Bilateral nonobstructing renal calculi are unchanged. Tiny calcifications at the left UVJ are unchanged. Marked dilation of the left renal collecting system and left proximal and mid ureter and thinning of the left renal parenchyma are unchanged. Metallic densities between the rectum and sacrum are unchanged. Diffuse atherosclerotic calcifications of the abdominal aorta and its branch vessels. Right renal artery stent. No bowel dilation. Suture material at the rectosigmoid junction. Shotty periportal and mesenteric lymph nodes are similar to the prior study. Evaluation of the liver, gallbladder, spleen, and pancreas are limited on this noncontrasted study. The adrenals are unremarkable on this noncontrast exam.
1. Multiple bilateral pulmonary parenchymal bands, similar to prior study from 2008, likely scarring.
2. Small bilateral pleural effusions.
3. Unchanged severe left hydronephrosis.
4. Nonobstructing bilateral renal calculi.
5. Atherosclerosis.
6. Additional nonacute findings, as described above.
Severe left sided hydronephrosis and hydroureter with none visualization of the left ureteral jet.
Approach to hypercalcemia
Making the diagnosis:
Elevated albumin levels
corrected serum calcium concentration lowered by 0.8 mg/dL (0.2 mmol/L) for every 1 mg/dL increase of albumin or protein above normal levels
checking ionized calcium most accurate
Total serum calcium > 10.5 mg/dL (2.63 mmol/L)
Ionized fraction > 5.6 mg/dL (1.4 mmol/L)
Rule out:
24-hr U Cr
673 (L)
↑ Ca
Measure PTH
Measure 24-hour urinary calcium level
Primary hyper-parathyroidism
Familial hypocalciuric hypercalcemia
Further measurement of 25-OH vitamin D may be needed to differentiate FHH from primary hyperparathyroidism with concomitant vitamin D deficiency
Measure PTHrP & Vitamin D
Elevated 25D
Check medications, vitamins, supp.
Vit D (N)
Consider other causes
Measure: SPEP, UPEP, TSH, Vit A
Consider chest X-ray
(r/o Lymphoma or granulomatous dz, i.e. sarcoid or TB
Elevated PTHrP
Scan for malignancy
adenocarcinoma or SSC
(e.g. lung tumor)
Loop Diuretics
with or without Loop Diuretics
Increase urinary calcium excretion via inhibition of calcium reabsorption in the loop of Henle.
may be used to augment calcium excretion once volume has been repleted.
in patients with renal insufficiency or heart failure, loop diuretics may be required to prevent fluid overload during hydration.
- 1st line
- Mechanism:
Restoration of intravascular volume
Increases urinary calcium excretion
Inhibits bone resorption via interference with osteoclast function
Promotes urinary calcium excretion
Medications of choice
for severe hypercalcemia

Inhibit bone resorption via interference with osteoclast recruitment and function
Indication: hypercalcemia due to:
vitamin D overdose
malignancy - lymphoma
granulomatous disease
Decrease intestinal calcium absorption
Decrease 1,25-dihydroxyvitamin D production by activated mononuclear cells in patients with granulomatous diseases or lymphoma
Inhibits osteoclast-mediated bone resorption
Calcium sensing receptor agonist, reduces PTH (parathyroid carcinoma, secondary hyperparathyroidism in CKD)
Gallium nitrate
Chief Complaint
Physical exam
May be asymptomatic
Bone pain
Anorexia/weight loss
Abdominal pain
Impaired concentration and memory
Muscle weakness
Ask about thiazides
Nephrogenic diabetes insipidus
Osteitis fibrosa cystica (hyperparathyroidism)
Peptic ulcer disease
Familial hypercalciuric hypercalcemia
e.x. kidney stones
Tobacco use (lung cancer)
General: confusion/stupor/coma; hypertension
HEENT: corneal calcification
Neck: check for thyroid nodule (10%-20%), palpable parathyroid (<1%)
Chest: breast and axillary masses which may suggest breast cancer
Cardiac: arrhythmias
Lungs: focal findings may rarely occur with lung cancer
Extremities: fractures, calcification, clubbing may be associated with lung cancer
Neuro: hyporeflexia (unusual)
Rectal: if malignancy suspected, examine prostate for lumps, check for rectal masses and guaiac stool for occult blood
Some ... Mechanism of Action
Hypercalcemia in Children • Posted by Graham McMahon • February 11th, 2011 • http://blogs.nejm.org
Prednisone 60mg prior to discharge ?
? Inclusion body myoisitis
vs. sarcoid myositis
Calcified band on CT-chest
Missed cytology in 2008
DDx granul. vs. lymphoma.
Lymph node biopsy.
PET scan.
3.8 (N)
Atypical mildly increased uptake in the bilateral hilar regions
Linear opacities in the lungs
Mildly increased uptake is seen in multiple thoracic vertebral bodies
Full transcript