Hypercalcaemia and Multiple Myeloma

Question 1

What is the initial treatment of hypercalcaemia?and alternative.

Answer 1

IV fluids to facilitate urinary calcium loss

If ineffective then furosemide

Question 2

List three common symptoms of hypercalcaemia

Answer 2

Confusion, lethargy and fatigue

Question 3

What is the best initial test for Multiple myeloma? Also provide the alternative

Answer 3

Serum protein electrophoresis or urine electrophoresis

Alternative: Bence Jones proteins in urine

They reveal monoclonal gammopathy

Question 4

Name two commonest causes of hypercalcaemia

Answer 4

Hyperparathyroidism and malignancy

Question 5

Name three drugs that cause hypercalcaemia

Answer 5

Calcium antacids
Thiazides diuretics
Lithium

Question 6

Name two granulomatous diseases associated with hypercalcaemia

Answer 6

Tuberculosis
Sarcoidosis

Question 7

What is the most likely cause of a patient with symptomatic hypercalcaemia?

Answer 7

Malignancy

Remember primary hyperparathyroidism is the most common but typically have asymptomatic hypercalcaemia

Question 8

Is multiple ,yellow the only cancer that can lead to hypercalcaemia?

Answer 8

Nope, even leukemia and lymphoma

And solid cancers such as breast, lung and kidney cancers

Question 9

List three complications of hypercalcaemia in the kidney

Answer 9

Pre-renal azotemia
Kidney stones
Nephrogenic diabetes insipidus

Question 10

List GI symptoms of severe hypercalcaemia 4

Answer 10

Constipation
Nausea
Loss of appetite
Peptic Ulcer disease

Question 11

List 4 symptoms of hyperparathyroidism

Answer 11

Abdominal pain
Myalgias
Bone pain
Altered mental status
Kidney stones

Question 12

State the diagnosis of primary hyperparathyroidism

Answer 12

Hypercalcaemia with hypophosphatemia and hyperparathyroidism

Question 13

List 5 indications for parathyroidectomy

Answer 13

Symptomatic hypercalcaemia
Kidney problems such as stones, pre-renal azotemia
Osteoporosis
Calcium that is 1 mg/dl above the upper normal limit
Patient<50 years old

Question 14

State how multiple myeloma is diagnosed.

Answer 14

The diagnosis of multiple myeloma requires laboratory and clinical criteria:
1. A monoclonal antibody spike in
the serum, or light chains in the urine;

2. More than 10% clonal plasma cells in the
   bone marrow; and
3. End-organ damage such as lytic bone lesions.

Question 15

What is the best diagnostic/confirmatory test flex multiple myeloma

Answer 15

Bone biopsy which reveals more than 10% clonal plasma cells in bone marrow

Question 17

What is monoclonal gammopathy of undetermined significance

Answer 17

Patients with lower level monoclonal immunoglobulin (Ig) A or IgG antibody
production without the signs or symptoms of multiple myeloma

Note: approximately 1% per year of these patients with MGUS will progress
to develop multiple myeloma.

Question 18

What is the treatment for multiple myeloma

Answer 18

Autologous stem cell transplant and induction chemotherapy with high-dose pulsed dexamethasone, in combination with thalidomide or lenalidomide, and bortezomib.

Question 19

What is soldering myeloma?

Answer 19

Patients with myeloma with no bone lesions or other end-organ damage

Require no treatment rather observe

Question 20

Adverse effects of bisphosphonates 4

Answer 20

Hypocalcemia, hypophosphatemia, hypomagnesemia and osteonecrosis of jaw

Question 21

List 3 common treatment of severe hypercalcaemia used acutely.

Answer 21

Hydration with/without furosemide
Additional: Calcitonin
Alternative: Dialysis

Question 22

Three adverse effects of glucocorticoids

Answer 22

Immune suppression
Osteoporosis
Hyperglycaemia

Question 23

Can glucocorticoids be used in the management of severe hypercalcaemia?

Answer 23

Yes, chronically together with bisphosphonates

Question 24

Name three endocrine conditions that cause hypercalcaemia.

Answer 24

Hyperparathyroidism
Adrenal insufficiency
Hyperthyroidism

Question 25

Can you treat asymptomatic multiple myeloma?

Answer 25

Only treat SYMPTOMATIC myeloma. If calcium is high bisphosphonates can be given

Question 26

What is lofgren syndrome

Answer 26

an acute presentation of sarcoidosis,
which includes hilar adenopathy, erythema nodosum, migratory polyarthralgia, and fever, seen most often in women

Question 28

A 58-year-old man with a history of gastroesophageal reflux disease (GERD), hypertension, and chronic back pain presents to the emergency department with progressive fatigue, confusion, diffuse muscle weakness, and polyuria for the past several days. His wife reports that he has also had intermittent nausea and vomiting.

His medications include hydrochlorothiazide for hypertension and frequent over-the-counter calcium carbonate antacids for chronic heartburn, which he has been taking in high doses (up to 5–6 grams daily) for the past several months. He also takes a vitamin D supplement. He denies recent illness, diarrhea, or diuretic overuse.

On examination:

Vitals: BP 160/90 mmHg, HR 65 bpm, RR 14/min, afebrile

General: Appears mildly dehydrated with dry mucous membranes

Neurologic: Alert but sluggish in response, 4/5 strength in all extremities, hyporeflexia

Laboratory findings:

Serum calcium: 14.2 mg/dL (elevated)

Serum phosphorus: 1.8 mg/dL (low)

Serum creatinine: 2.8 mg/dL (elevated from baseline of 0.9 mg/dL)

Bicarbonate: 38 mEq/L (elevated)

PTH: Suppressed

25-hydroxyvitamin D: Normal

Urine chloride: 15 mEq/L (low)

EKG: Shortened QT interval, no arrhythmias

ABG shows metabolic alkalosis (pH 7.52, PaCO₂ 50 mmHg).

What is the diagnosis?

Answer 28

Diagnosis: Given his excessive calcium carbonate ingestion, suppressed PTH, hypercalcemia, acute kidney injury, metabolic alkalosis, and low urine chloride, the patient is diagnosed with severe milk-alkali syndrome exacerbated by hydrochlorothiazide use.