hypercalcaemia (case presentation)
DESCRIPTION
A case of hypercalcaemia with 2 possible aetiologies with a discussion of calcium and bone disordersTRANSCRIPT
Intern Case PresentationMrs EB
Overview• Mrs B, 80yo woman, home alone, I with ADLs• Presents with:
▫ 1/52 vomiting & diarrhoea, fatigue, malaise▫ 5/7 constipation▫ 3-4/7 severe generalised abdominal pain▫ ~20kg weight loss since 4/08!▫ Nil fevers/sweats; nil haematemesis/melaena/PR bleed
• PHx▫ Metastatic breast ca T3, ribs, femur, lungs on
exemestane, monthly zolendronic acid (Zometa)▫ Sick sinus sx (PPM inserted 4/4/08)▫ Parathyroid adenoma▫ Past DVT/PE on warfarin▫ Rx: tamoxifen, warfarin, perindopril, vitamin D,
pantoprazole, bisoprolol, GTN
Further PMHx
•Breast Ca:▫Dx 26 years ago: mastectomy, chemo,
radiotherapy▫Recurrence 5 years ago; lung mets
discovered and resected; commenced on aromatase inhibitor
▫4/08: bony mets ribs 8 & 9, T3, femur Switched from aromatase inhibitor
tamoxifen Commenced on monthly zolendronic acid
(bony mets)
Further PMHx
•Parathyroid adenoma:▫Episode of hypercalcaemia 4/08▫PTH found to be high ?cause▫Sestamibi parathyroid scan: area of avid
sestamibi uptake right lower neck corresponding to 2.0x1.0cm density on SPECT/CT ?parathyroid adenoma
▫Surgery refused at this stage•Sick sinus syndrome:
▫Permanent pacemaker inserted 4/08
Examination Findings• General findings
▫Unwell thin looking elderly lady▫JVP low▫Dry mucous membranes▫BP 110/50, HR 100/regular, SaO2 95% RA,
afebrile• Abdominal exam
▫Generalised tenderness w/o peritonism▫Bowel sounds present
• Chest▫Clear lung fields▫Dual heart sounds no added sounds
Investigations
•FBE: Hb 143/WCC 9.7/PLT 268•UEC: Na 129/K 3.3 Urea 13.4 Creat 92
eGFR 54 (baseline >60)•Ca2+: 3.29; albumin 37; corr ca 3.35;
Phos 0.75; Mg2+ 0.61•CRP 1.4, LFT normal•AXR: multiple fluid-air levels suggestive of
small bowel ileus.•CXR: old right lower zone changes
Diagnosis
•Hypercalcaemia causing secondary ileus and marked volume depletion
•Dx Dilemma: cause = bony mets, parathyroid tumour or both?
Initial Management
•Rehydration: 1L N. Saline/2hrs (ED), 4L N. Saline/24hrs (and continued)
•Not for bisphosphanates as already on monthly zolendronic acid
•Ileus managed conservatively
Further Ix & Mx
• PTH 6/4/08 = 26.3, Sestamibi- right lower neck PTH adenoma; sestamibi-avid metastatic disease right ribs, pleura, hilum ?PTHrP secreting mets
• Endocrinology:▫Dx likely due to combination of met breast ca and
primary parathyroidism▫Recommended surgical referral for r/o adenoma
• However: PTH now = 0.1 (Suppressed by very high calcium?)
• Sestamibi scan for diagnosis of parathyroid lump, surgical opinion to follow
• Therefore diagnosis: Hypercalcaemia secondary to bony metastatic disease.
Date 0145 24/6
0731 24/6
1900 24/6
0950 25/6
26/6
Calcium 3.29 2.84 2.92 2.81 2.57
Hypercalcaemia
The presentationof Hypercalcaemia
can be as vagueand confusingas this patient!
Calcium, Vit D, PTH metabolism
Calcium, Vit D, PTH metabolism
Calcium, Vit D, PTH metabolism
Causes :: Overview• Parathyroid Adenomas• Malignancy• Renal failure• Paget’s Disease• Drugs – thiazides, calcium, lithium…• Endocrine: Hyperthyroidism, addisonism• Genetic – Hypervitaminosis D,
Hypercalcaemic hypocalciuria• Sarcoidosis, Granulomatosis (incl TB)
Account for >90% of cases!
Causes :: When to suspect
•Past history of malignancy- esp bony mets, multiple myeloma
•Endocrine problems•On calcium supplementation•Renal patients•Old people, delirium, confusion of unknown
aetiology•Specific drugs – calcium, lithium, thiazides,
vitamin D etc•Other indicators in HOPC/PHx
Causes :: Malignancy (Poor prognostic factor)
Investigations• Serial Ca, PO4• Correct Ca with albumin!!
▫ (40-Alb)*0.2 + serum Ca = corrected Ca• UEC – renal function (ARF 2°
dehydration/hypercalcaemia, CRF causing hypercalcaemia)
• PTH level, ALP, Vit D• Consider multiple myeloma screen – ESR, serum
electrophoresis, urine BJP etc.• Consider ordering urine calcium – 24 hour urine
calcium collection• High PTH - Hyperparathyroidism: Sestamibi
parathyroid scan• Low PTH - Malignancy: CT chest, abdo, pelvis, bone
scan
Management• REHYDRATE aggressively with normal saline (aim
for 200-300mL/hr initially then urine output 100-150mL/hr)▫ Volume depletion most dangerous complication acutely▫ Na+, H2O administration renal Ca excretion
• Frusemide if overloaded – promotes renal ca excretion
• IV bisphosphanate eg pamidronate if Ca>3• Calcitonin if Ca resistant to intervention• Steroids in granulomatous disease, multiple
myeloma, others• If Ca still doesn’t come down- consider
haemodialysis
And of course…•Treat the underlying cause.•Renal failure:
▫ 2° hyperparathyroidism (high PTH) Calcimimetics – cinacalcet Vit D analogues (not increasing Ca) – paracalcitriol
▫ 3° hyperparathyroidism (autonomic PTH) Surgical intervention
•Parathyroid nodule/tumour: surgical intervention•Granulomatous disease: steroids•Drugs: cease offending drug•Treat endocrine conditions