2. 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?

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

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

5. Calcium Metabolism

6. Definition  Total Corrected Serum Ca 2+ >2.62 mmol/L OR  Ionized Ca 2+ > 1.35 mmol/L Corrected = measured Ca 2+ + 0.02 (40-albumin) Or for every ↓5 of albumin, add 0.1 to serum Ca

8. 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

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

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

12. 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

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

14. Other less common causes:

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

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

17. 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

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

19. 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

20. 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?

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

22. The End