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Hypercalcaemia (Case Presentation)
 

Hypercalcaemia (Case Presentation)

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A case of hypercalcaemia with 2 possible aetiologies with a discussion of calcium and bone disorders

A case of hypercalcaemia with 2 possible aetiologies with a discussion of calcium and bone disorders

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    Hypercalcaemia (Case Presentation) Hypercalcaemia (Case Presentation) Presentation Transcript

    • Intern Case Presentation Mrs 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 presentation of Hypercalcaemia can be as vague and confusing as 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