Hypercalcaemia

Question 1

A 59 year old female attends a diabetes clinic annually for review. You notice her serum calcium concentration has been above the upper limit of normal for the last 3 years, currently 2.79 mml/L (NR<2.6 mmol/L). How would you investigate and manage this?

Imp/DDx/Goals

Answer 1

Impression:
Hypercalcaemia based on serum electrolyte results. The most common causes of hypercalcaemia in adults are primary hyperparathyroidism, or hypercalcaemia of malignancy, this being largest concern in this patient. Otherwise, medications such as thiazide diuretics, or vitamin D toxicity may cause a hypercalcaemia.

DDx

• Myeloma
• Sarcoidosis - often picked up as hypercalcaeima
• Thiazide diuretics
• Vit D toxicity

Goals:

• identify underlying aetiology of the hypercalcaemia, often asymptomatic
• initiate appropriate management of the condition

Question 2

Hypercalcaemia - History

Answer 2

History

• sx: Stones, bones, groans, thrones, psychiatric overtones
• Features of malignancy
• Sx of uncontrolled diabetes
• PMHx: malignancies (paraneoplastic syndrome of small cell lung cancer,
• FamHx: malignancies
• medications: thiazide diuretics, vitamin d
• SNAP/diabetes control

Question 3

Hypercalcaemia - Examination

Answer 3

Examination

• General observation + vital signs
• No specific findings indicative of hypercalcaemia
• Thyroid examination: parathyroid nodule
• Systems review: assess for evidence of malignancy (wasting, bony pain, masses, etc)

Question 4

Hypercalcaemia - Investigations

Answer 4

Investigations:
- Key/diagnostic: Corrected calcium (serum calcium, serum albumin), PTH level, PTHrP level

• Bedside: ECG (arrhythmias)
• Bloods: UEC, PTH level, PTHrP, CMP, FBC, CRP/ESR, TFT, electrophoresis for myeloma
• Imaging: dependent on above results. Neck US if suspicious of parathyroid tumour, Sestameby scan (nuclear medicine scan)

Question 5

Hypercalcaemia - Management

Answer 5

Management for hypercalcaemia
Mild (asymptomatic)
- oral rehydration
- avoid calcium-raising medications
- limit daily calcium intake

Mod-severe (symptomatic)

• IV rehydration therapy (NS) - treats hyperCa and prevents further kidney function deterioration which would worsen Ca levels (4-6L NS)
• consider bisphosphonates/denosumab
• dialysis if severely elevated

Definitive:

• surgical resection of parathyroid tumour
• Removal and successful treatment of underlying malignancy (MDT)