case 1
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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?
Case 2 70M with known Lung CA, presents with
acute psychosis and Ca= 3.4 mmol/L
Management?
Hypercalcemia
Lab RoundsSultana Qureshi, PGY-2August 3, 2006
Calcium Metabolism
Hormone Effect on bones Effect on gut Effect on kidneys
Parathyroid hormone Ca++, PO4 levels in blood
Supports osteoclast resorption
Increases absorption via Vit D
Supports Ca++ resorption and PO4 excretion, activates 1-hydroxylation
Vit D Ca++, PO4 levels in blood
- Ca++ and PO4
absorption -
Calcitonin Ca++, PO4 levels in blood
when hypercalcemia is present
Inhibits osteoclast resorption
- Promotes Ca++ and PO4 excretion
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
Symptoms“Bones, Stones, Groans, Moans”
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 (cont’d)“Bones, Stones, Groans, Moans”
Psychiatric (Moans)
> 3mmol/L Increased alertness Anxiety/Depression Cognitive Dysfunction Organic Brain Syndromes
> 4mmol/L Psychosis
ECG
Changes:
-shortening of QT
-prolongation of PR
-ST depressions
U- waves
Severe:
-bradyarrythmias
-BBB and high AV block
-potentiates Digoxin effects
-Cardiac Arrest
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
Other common causes
Iatrogenic/DrugsThiazidesLithiumHypervitaminosis A & D
Granulomatous DiseaseSarcoidosisTuberculosis
Other less common causes:
Parathyroid hormone-related Sporadic, familial, associated with multiple endocrine neoplasia I or II Tertiary hyperparathyroidism Associated with chronic renal failure or vitamin D deficiency Vitamin D-related Vitamin D intoxication Usually 25-hydroxyvitamin D2 in over-the-counter supplements Hodgkin's lymphoma Genetic disorders Familial hypocalciuric hypercalcemia: mutated calcium-sensing receptor
Medications Milk-alkali syndrome (from calcium antacids) Other endocrine disorders Hyperthyroidism Adrenal insufficiency Acromegaly Pheochromocytoma Other Immobilization, with high bone turnover (e.g., Paget's disease, bedridden child) Recovery phase of rhabdomyolysis
Who needs immediate ED treatment?
Ca > 3.5 mmol/L
Ca > 3 mmol/L with symptoms
Management
Four Goals
1) Correct Hypovolemia
2) Increase renal calcium excretion
3) Reduce osteoclastic activity
4) Treat primary disorder
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
Management
2) Increase renal calcium excretionCorrecting HypovolemiaLasix 10-40 mg IV q6-8h Dialysis in patients with renal failure
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
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?
Case 2 70M with known Lung CA, presents with
acute psychosis and Ca= 3.4 mmol/L
The End