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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 Rounds Sultana Qureshi, PGY-2 August 3, 2006 Calcium Metabolism Effect on bones Effect on gut Effect on kidneys Parathyroid hormone Ca++, PO4 levels in blood Supports osteoclast resorption Increases Supports Ca++ resorption and absorption via Vit PO4 excretion, activates 1D 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 Hormone 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 Bone pain Fractures/Deformities Constipation Abdo pain Anorexia & W.L., NV PUD, pancreatitis Dysrhythmias ECG changes HTN, vascular calcification Renal (Stones) GI (Groans) Cardiovascular Weakness, malaise, dehydration Skeletal (Bones) 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 25-75/100 000 (US) mcc Parathyroid adenoma Usually mild hyperCa High PTH (30-50%) 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/Drugs Thiazides Lithium Hypervitaminosis A & D Granulomatous Disease Sarcoidosis Tuberculosis 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 excretion Correcting Hypovolemia Lasix 10-40 mg IV q6-8h Dialysis in patients with renal failure Management 3) Reduce osteoclastic activity Bisphosphonates Calcitonin In severe cases, 4 un/kg SQ q6h Starts working with a few hours Glucocorticoids Pamidronate 60-90 mg IV over 4 hours Max effect in 72 hours More effective in hyperCa of malignancy 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