Hypercalcaemia & Hyperparathyroidism

Question 1

what are the typical symptoms associated with hypercalcaemia

Answer 1

bony pain, kidney pain, abdo pain, psychiatric disturbance

bones, stones, abdominal groans, psychiatric moans

Question 2

what can patients acute hypercalcaemia present with

Answer 2

thirst, dehydration, confusion, polyuria

Question 3

what signs/symptoms can occur with chronic hypercalcaemia

Answer 3

myopathy, fractures/osteopenia, depression, hypertension, kidney stones, pancreatitis

Question 4

what are the 2 main causes of hypercalcaemia

Answer 4

primary hyperparathyroidism and malignancy

Question 5

what are some of the less common causes of hypercalcaemia

Answer 5

drugs(eg vit D), granulomatous disease, familial hypocalciuric hypercalcaemia(FHH)

Question 6

what is the upper limit range of corrected calcium

Answer 6

2.55, anything over is hypercalcaemia

Question 7

what is the most useful biochemical test in diagnosis of the cause of hypercalcaemia

Answer 7

parathyroid hormone(PTH)

Question 8

what are the different hypercalcaemia causes that result in high PTH

Answer 8

primary(or tertiary) hyperparathyroidism, or familial hypocalciuric hypercalcaemia(FHH)

Question 9

what is the cause of hypercalcaemia with a low PTH

Answer 9

not hyperparathyroidism, likely malignancy

Question 10

how can differentiation between hyperparathyroidism and FHH be made

Answer 10

hyperparathyroidism = increase urine Ca excretion
FHH = decreased urine Ca excretion

Question 11

what further diagnostic biochemical test is done after establishing hypercalcaemia with low PTH

Answer 11

ALP

Question 12

if ALP is raised in hypercalcaemia with low PTH, what are the differential diagnosis

Answer 12

metastases, sarcoidosis, thyrotoxicosis

Question 13

if ALP is low in hypercalcaemia with low PTH, what are the differential diagnosis

Answer 13

myeloma, vit D toxicity, Milk-Alkali syndrome

Question 14

what 3 things must be present in diagnosis of primary hyperparaathyroidism

Answer 14

raised serum Ca2+, raised serum PTH(or inappropriately normal), increased urine Ca2+ excretion

Question 15

what different mechanisms can cause hypercalcaemia in malignancy

Answer 15

metastatic bone destruction(tumour in bon releasing Ca), PTHrp from solid tumours, osteoclast activating factors(breakdown bone)

Question 16

what investigations can be done in the diagnosis of hypercalcaemia caused by malignancy

Answer 16

diagnosis involves; raised Ca2+, raised ALP, and imagery such as X-ray, CT, MRI, PET, isotope bone scan

Question 17

what initial treatment is usually used for acute hypercalcaemia

Answer 17

fluids rehydrate with 0.9% saline 4-6L in 24 hours, and bisphosphonates

Question 18

what other treatments are considered for treatment of acute hypercalcaemia

Answer 18

loop diuretics once rehydrate(avoid thiazides), steroids occasionally(eg sarcoidosis), chemo if malignancy

Question 19

what are the different treatment options for primary hyperparathyroidism

Answer 19

surgery(parathyroidectomy), or cinacalcet

Question 20

what type of drug is and when would Cinacalcet be used as treatment for primary hyperparathyroidism

Answer 20

calcium mimetic, can be used if unfit for surgery, approved for tertiary hyperparathyroidism and parathyroid carcinoma

Question 21

what are the indications for a parathyroidectomy in primary hyperparathyroidism

Answer 21

if patients has; end organ damage, very high serum Ca2+ >2.85mmol/l, <50y/o, eGFR <60mL/min

Question 22

what end organ damage can occur in primary hyperparathyroidism

Answer 22

bone disease, gastric ulcers, renal stones, osteoporosis

Question 23

what is the difference between primary and secondary hyperparthyroidism

Answer 23

primary = primary overactivity of parathyroid gland, high PTH, high Ca
secondary = response to low Ca or vit D, high PTH, low Ca

Question 24

what genetic syndromes is hyperparathyroidism involved in

Answer 24

MEN 1/2 and familial isolated hyperparthyroidism

Question 25

describe the pathophysiology of FHH

Answer 25

calcium-sensing receptor becomes much less sensitive, so no PTH inhibition, high serum Ca, low urine Ca

Question 26

describe the biochemistry seen in primary hyperparathyroidism

Answer 26

high Ca, high PTH, normal/raised ALP, low phosphate

Question 27

describe the biochemistry seen in hypercalcaemia caused by malignancy

Answer 27

high Ca, low PTH, very high ALP, normal phosphate