Hypercalcemia

Hypercalcemia, or elevated blood calcium, is above the normal range of 2.2-2.6 mmol/L (9-10.5 mg/dL). Symptoms begin appearing above 3 mmol/L, while hypercalcemia above 3.75 mmol/L (15-16 mg/dL) is considered a medical emergency. Ionized calcium should be less than 1.23.

 

 

Causes and Risk Factors

Hypercalcemia can result from a number of processes:

 

Causes include

Hyperparathyroidism

  • adenoma, hyperplasia, carcinoma

Malignancy: ectopic production of PTHrP, osteolytic cytokines (lymphotoxin, TNF, IL-1a and b, TGFa) calcitriol

  • lung, breast, prostate, renal, thyroid, GI, melanoma, sarcoma, multiple myeloma, lymphoma, leukemia

drug induced

  •  vitamin A, thiazides, lithium, tamoxifen

granulomatous conditions

  • sarcoid can increase vitamin D
  • infections such as TB)

endocrine

  • Addison's, hyperthyroidism, acromegaly 

familial, renal failure

 

 

 

Signs, Symptoms, and Diagnosis

Clinical features depend on duration and severity, and include:

  • history and physical exam
  • lab investigations
  • ECG changes
  • diagnostic imaging

History and Physical Exam

stones, moans, bones, psychiatric overtones

 

neurologic symptoms

  • fatigue, drowsiness, decreased concentration, confusion
  • weakness, decreased reflexes
  • depression
  • psychosis
  • coma

GI symptoms

  • abdominal pain
  • loss of appetite, weight loss
  • constipation 
  • nausea, vomiting
  • pacreatitis, peptic ulcer disease

renal sypmtoms

  • impaired concentrating ability
  • polyuria, polydypsia (early symptoms)
  • nephrolithiasis (1e hyperparathyroidism)
  • nephrocalcinosis

skin lesions

  • purpura, ecchymosis, petechiae

look for enlarged lymph nodes, speen, liver if malignincy is suspected

Lab Investigations

 It is important to use corrected Ca2+. Take measured albumin: 40-x. Multiply this by 0.02 and add to measured Ca2+.

 

blood tests

  • calcium and albumin
  • Mg, PO4
  • PTH, PTHrP
  • Alk Phos - bone involvement
  • vitamin D
  • serum protein electrophoresis
  • tumour markers
  • ESR - malignancy

urinalyisis

  • 24 hour urine collection for Ca PO4, and creatinine

ECG Changes

  • shortened Q-T interval
  • bradycardia
  • primary AV block

 

Diagnostic Imaging

Chest X-ray can assess for lung cancer and sarcoidosis.

Pevlic X-ray.

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Treatments

 

Fluids are very important to flush calcium from the body. Urine calcium loss can be enhanced using diuretics (furosemide) or calcitonin. Glucocorticoids can also assist renal excretion.

 

Decreased intestinal absorption (glucocorticoids, phosphate) and by inhibiting osteoclasts

Dialysis can be used if calcium levels are not dropping, if patient is in congetive heart failure.

 

The underlying cause should be identified and treated as calcium levels are controlled.

 

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Consequences and Course

 

 

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Resources and References