Morning Report: 12/6/2013

Thanks to Dr. Louis for today’s Morning Report!

Hypercalcemia

Definitions:

– The normal reference range of serum calcium levels in adults is 8.7-10.4 mg/dL

– Mild hypercalcemia is 10.5 – 11.9 mg/dL

– Moderate hypercalcemia is 12.0-13.9 mg/dL

– Severe hypercalcemia is > 14.0 mg/dL

Epidemiology:

-Primary hyperparathyroidism is most common cause of mild hypercalcemia, with over 50,000 new cases per year.

– 20-40% of patients with cancer develop hypercalcemia at some point in disease

-Prognosis of hypercalcemia associated with malignancy is poor; 1 year survival rate of 10-30%

Presentation:

-Moans, groans, stones, bones, psychic overtones

-Mild elevations usually have few or no symptoms

– Nausea; vomiting; ams; abdominal pain; constipation; generalized weakness and fatigue; joint pains; headache; confusion; lethargy; depression; polyuria, polydipsia, nocturia.

Causes:

1. Primary hyperparathyroidism – PTH mediated
2. Non-PTH mediated
   1. Malignancy
   2. Granulomatous disorders (increased calcitriol production from macrophages)
   3. Iatrogenic
   4. Pharmacologic agents (i.e. thiazide, lithium, calcium carbonate, hypervitaminosis D)
   5. Endocrinopathies (nonparathyroid)
   6. Familial hypocalciuric hypercalcemia
   7. Tertiary hyperparathyroidism

Workup:

–       Correct for total calcium based on albumin

–       Get an ionized calcium

–       EKG – Changes include QT interval shortening, prolonged PR interval

Treatment

–       IVF hydration

–       Loop diuretics

–       Bisphosphonates

–       Calcitonin

–       Discontinue contributing pharmacologic agents

–       Underlying cause (when possible)

–       Dialysis for severe cases with renal failure

References:

• Stewart F.  Hypercalcemia Associated With Cancer.N Engl J Med. 2005; 352:373-379
• Hemphill R. (April 2013) Hypercalcemia in Emergency Medicine. Emedicine. Emedicine.medscape.com.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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