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?