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Case 1

Case 1. 53F presents to ED with dysuria PMHx: HTN, Hyperlipidemia, UTI is diagnosed and oral Abx script given Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L On further history the patient states she has no symptoms and has been otherwise well.

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Case 1

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  1. Case 1 • 53F presents to ED with dysuria • PMHx: HTN, Hyperlipidemia, • UTI is diagnosed and oral Abx script given • Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L • On further history the patient states she has no symptoms and has been otherwise well. • Management? Disposition?

  2. Case 2 • 70M with known Lung CA, presents with acute psychosis and Ca= 3.4 mmol/L • Management?

  3. Hypercalcemia Lab Rounds Sultana Qureshi, PGY-2 August 3, 2006

  4. Calcium Metabolism

  5. Definition • Total Corrected Serum Ca2+ >2.62 mmol/L OR • Ionized Ca2+ > 1.35 mmol/L • Corrected = measured Ca2+ + 0.02 (40-albumin) • Or for every ↓5 of albumin, add 0.1 to serum Ca

  6. General Weakness, malaise, dehydration Skeletal (Bones) Bone pain Fractures/Deformities GI (Groans) Constipation Abdo pain Anorexia & W.L., NV PUD, pancreatitis Cardiovascular Dysrhythmias ECG changes HTN, vascular calcification Renal (Stones) Nephrolithiasis Polyuria, polydipsia, nocturia Nephrogenic DI Renal failure Neurologic Hypotonia, Hyporefelxia, ataxia Myopathy Paresis Altered LOC/Coma Symptoms“Bones, Stones, Groans, Moans”

  7. Symptoms (cont’d)“Bones, Stones, Groans, Moans” • Psychiatric (Moans) • > 3mmol/L • Increased alertness • Anxiety/Depression • Cognitive Dysfunction • Organic Brain Syndromes • > 4mmol/L • Psychosis

  8. ECG Changes: -shortening of QT -prolongation of PR -ST depressions U- waves Severe: -bradyarrythmias -BBB and high AV block -potentiates Digoxin effects -Cardiac Arrest

  9. Causes • 90% of cases due to • Primary Hyperparathyroidism (30-50%) • 25-75/100 000 (US) • mcc Parathyroid adenoma • Usually mild hyperCa • High PTH • Malignancy (40%) • 20-30% of Cancer patients • Poor prognosis – 1 yr survival = 10-30% • Lung/Breast/Kidney/Myeloma/Leukemia • More likely to be encountered in ED • Low PTH • 2 mechanisms: PTHrP or osteolytic

  10. Other common causes • Iatrogenic/Drugs • Thiazides • Lithium • Hypervitaminosis A & D • Granulomatous Disease • Sarcoidosis • Tuberculosis

  11. Other less common causes:

  12. Who needs immediate ED treatment? • Ca > 3.5 mmol/L • Ca > 3 mmol/L with symptoms

  13. Management • Four Goals 1) Correct Hypovolemia 2) Increase renal calcium excretion 3) Reduce osteoclastic activity 4) Treat primary disorder

  14. Management • 1) Correct Hypovolemia • Decreases Ca by 0.4 - 0.6 • Increases GFR & Na load to kidneys, thus Ca excretion • Various recommendations • NS IV @ 200-300cc/hr. • Usually require 2-4L per day X 1-3 days. • Aim for U/O of 200 cc/hr • Caution with elderly, poor LV function • Also, correct co-existing electrolyte abnormalities

  15. Management • 2) Increase renal calcium excretion • Correcting Hypovolemia • Lasix 10-40 mg IV q6-8h • Dialysis in patients with renal failure

  16. Management • 3) Reduce osteoclastic activity • Bisphosphonates • Pamidronate 60-90 mg IV over 4 hours • Max effect in 72 hours • More effective in hyperCa of malignancy • Calcitonin • In severe cases, 4 un/kg SQ q6h • Starts working with a few hours • Glucocorticoids • In Vit D mediated hyperCa (Vit D intoxication, hematologic malignancies, Granulomatous disease) • Hydrocortisone 200-300mg IV qd X 3 days • Mythramycin, Gallium Nitrate, IV phosphate – no longer used

  17. Case 1 • 53F presents to ED with dysuria • PMHx: HTN, Hyperlipidemia, • UTI is diagnosed and oral Abx script given • Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L • On further history the patient states she has no symptoms and has been otherwise well. • Management?

  18. Case 2 • 70M with known Lung CA, presents with acute psychosis and Ca= 3.4 mmol/L

  19. The End

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