Hyper Calc Emi A by a student

7/27/2019 Hyper Calc Emi A by a student

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Hypercalcemia

Ayesha Shaikh

Emory Family MedicineResidency Program


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Introduction

62 years old Nepali female

Cc: Hypertension, indigestion and fatigue

since past many years.


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HPI

1- Hypertension for 10 years , treated with Amlodipine 5 mg inNepal. CXR and blood tests normal at the time of immigration1 month ago. Denies

2- Epigastric abdominal pains since past many years, nonradiating, dull, 4/10, unrelated to the type or timing of foodingestion. Denies nausea, vomiting, diarrhea, constipation.

3- Fatigue for many years. No change in weight, mood orlimitations in daily activity. Denies depressive symptoms.

One prior FPC visit at Dunwoody Clinics for Medicines refill andnecessary labs ordered.


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PMH: Hypertension, no prior hospitalizations

PSH: noneSH: recent immigrant, lives with family

consisting of children and grand children.Good social support system. Daily chores.

Denies smoke or alcohol.ROS: Irritable mood,

Meds: Amlodipine 5 mg

No OTC medicine use

NKDA


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Physical exam

Petit elderly female, no acute distress

Vitals: Height: 5 1 Weight: 100 lbs BMI:20

T: 98.6 P: 61 BP: 154/98 RR: 12Chest

CVS

Abd: normal inspection, palpation, percussionand auscultation

Neuro: Cranial nerves intact, no motor orsensory deficit. Gait normal, reflexes 2+

ENT: Non palpable thyroid gland


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Labs and tests

CBC: normal

BMP: Na: 141 K 4.3,

Bun/creat: 10/0.80Glucose: 95

Calcium: 11.0

albumin: 4.6

Chloride: 107

CO2 21

LFT: WNL

TSH: 0.86

Lipid profile: T.Chol 186

TG 87

LDL 117

HDL 52

Urine Microalbumin/cr 0.2/30= 7

EKG

Previous labs!

Calcium 10.9


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Assessment and Plan

Hypertension: Amlodipine 5 mg

Hypercalcemia: Fup labs PTH

Gastritis: Pepcid

Backache: Lumbar spine X ray

Health maintenance: Flu vaccine andplan RPE visit.


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Test results

PTH: 127 (ref 10-65 pg/ml)

Lumber DJD

Parathyroid scan: Right lower Parathyroidadenoma

Follow up: Blood pressures > 150/90 mmhg,

increased amlodipine dose and added HCTZlater

Endocrinology referral for primaryhyperparathyroidsism


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Endocrinology workup

Exclude underlying secondaryhyperparathyroidism, since low vitamin

D levels very common in mountains ofHimalayas.

25 hydroxyVitaminD levels =10 (30-80)

Vitamin D replacement: 50,000 units/week for 8 weeks. Recheck calcium

and Vit D levels thereafter


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Hypercalcemia

Introduction: 1/500, incidental finding The skeleton contains 98 percent of total body

calcium; the remaining 2 percent circulates

throughout the bodyOne half of circulating calcium is free (ionized)

calcium, the only form that has physiologic effects. The remainder is bound to albumin, globulin, and

other inorganic molecules Corrected calcium = (4.0 mg/dl - [plasma albumin]) X

0.8 + [serum calcium]


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Defination

Normal serum calcium levels are 8 to 10mg/dL (2.0 to 2.5 mmol/L)

Normal ionized calcium levels are 4 to 5.6mg /dL (1 to 1.4 mmol per L)

Hypercalcemia is defined as total serum

calcium > 10.2 mg/dl(>2.5 m mol/L ) or

ionized serum calcium > 5.6 mg/dl ( >1.4 mmol/L )


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Defination

Severe hypercalemia is defined as total serumcalcium > 14 mg/dl (> 3.5 mmol/L)

Hypercalcemic crises is present when severeneurological symptoms orcardiac arrhythmiasare present in a patient with a serum calcium > 14

mg/dl (> 3.5 mmol/L) or when the serum calcium is >16 mg/dl (> 4 mmol/L)


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Hormone Effect on bones Effect on gut Effect on

kidneys

Parathyroid

hormone

increase Ca++,

decrease PO4

levels in blood

Supports

osteoclast

resorption

Indirect effects

via increase

calcitriol from 1-

hydroxylation

Supports Ca++

resorption and

PO4 excretion,

activates 1-

hydroxylation

Calcitriol

(vitamin D)

Ca++, PO4

levels increases

in blood

No direct effects

Supports

osteoblasts

Increases Ca++

and PO4

absorption

No direct effects

Calcitonincauses Ca++,

PO4 levels

decrease in

blood when

hypercalcemia is

present

Inhibitsosteoclast

resorption

No direct effects Promotes Ca++and PO4

excretion


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Pathophysiology

Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D3 (calcitriol), and calcitonincontrol calcium homeostasis in the body

Hypercalcemia is caused by Increased boneresorption, increased gastrointestinal absorptionof calcium, and decreased renal excretion ofcalcium


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Pathophysiology

Calcitonin Inhibits osteoclast resorption ,

promotes Ca++ and PO4 excretion

PTH-related peptide (PTHrP) binds the PTH

receptor and mimics the biologic effects of

PTH on bones and the kidneys


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Clinical manifestations

Hypercalcemia leads to hyperpolarization of

cell membranes

Patients with levels of calcium between 10.5and 12 mg /dl can be asymptomatic. When

the serum calcium level rises above this

stage, multisystem manifestations become

apparent


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Evaluation

Evaluation of a patient with hypercalcemia

should include a careful history and

physical examination focusing on clinicalmanifestations of hypercalcemia, risk factors

for malignancy, causative medications, and

a family history of hypercalcemia-

associated conditions


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Evaluation

Primary hyperparathyroidism : PTH

MALIGNANCY :

1.solid tumors(humoral hypercalcemia):PTHrP ,PTH

2.Multiple myeloma and breast cancer(osteolytichypercalcemia ) :

alkaline phosphatase ,PTH


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TREATMENT

Clinical indications for surgery in patients withprimary hyperparathyroidism

Significant symptoms of hypercalcemia

Nephrolithiasis

Decreased bone mass

Serum Calcium > 12 mg/dl

Age< 50 yearsInfeasibility of longterm follow up


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Pharmacologic options

Normal Saline 2-4 L IV daily for 1-3 days

Enhances filtration and excretion of CA++.

Indication: Ca > 14 mg/dl, moderate Calciumwith symptoms

Caution: may exacerbate heart failure in

elderly patients. Lowers Calcium by 1-3 mg/dl


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Furosemide 10-20 mg IV as necessary

Inhibits calcium resorption in distal renal

tubule.Indication: following aggressive

hydration

Caution: hypokalemia, dehydration ifused before intravascular volume isrestored


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Bisphosphonates

Pamidronate

Zoledronic acid

Inhibits osteoclast action and bone

resporption

Indication: hypercalcemia of malignancy


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Treatment

Calcitonin :

inhibition bone resorption and increases renal calcium excretion

4 to 8 IU per kg IM or SQ every 6 hours for 24 hours

Plicamycin (Mitharmycin) :

decreases bone resorption25 mcg per kg per day IV over 6 hours for 3 to 8 doses

Gallium nitrate :

inhibition bone resorption

100 to 200 mg per m2 IV over 24 hours for 5 days

Glucocorticoids :

Inhibits vitamin D conversionto calcitriol

Hydrocortisone, 200 mg IV daily for 3 days

Hemodialysis :

used in patients with renal failure


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Medical management of

primary

hyperparathyroidism medical therapy with drugs have not been shown to

affect the eventual outcome

estrogens (premarin 1.25mg/day) preserve bonemass in post-menopausal females

well-hydrated by drinking 2 - 3 litres of fluid, and 8 -10 g of salt daily

dietary restriction of calcium is not necessary ,thiazide diuretics must not be used

oral phosphate should only be used if symptomatichypercalcemia cannot be corrected surgically


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Medical management of

hypercalcemia in cancer

patients

2 - 3 litres per day + 8 - 10g of salt/day

Pamridonate can be used prn every few weeks tokeep the serum calcium in the normal range

Prednisone (20 - 50 mg bid) is only useful in certain

malignancies eg. multiple myeloma and certain

lymphomas


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Treatment

Medical management of other disorders :

--prednisone and low-calcium diet ( < 400 mg/day )

Medical management of hypercalcemia in

sarcoidosis :

--a low dose of prednisone (10 - 20 mg/day) is usually

adequate


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References

Carroll M, Schade D. A Practical

Approach to Hypercalcemia. American

Family Physician. May 1, 2003.Taniegra E. Hyperparathyroidism.

American Family Physician. January 15,

2004.

Hyper Calc Emi A by a student

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