Symptom To Diagnosis - Hypercalcemia Flashcards

1
Q

Most cases of hypercalcemia are due to only a handful of conditions:

A
  1. Primary hyperparathyroidism.
  2. Hypercalcemia of malignancy.
  3. Renal failure.
  4. Milk-alkali syndrome.
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2
Q

Etiology of hypercalcemia - PTH-related:

A
  1. Primary hyperparathyroidism. 2. 2o hyperparathyroidism (due to renal insufficiency and Ca or vitD supplementation). 3. Tertiary hyperparathyroidism. 4. Lithium therapy (10%). 5. FHH.
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3
Q

Hypercalcemia of malignancy:

A
  1. Secretion of PTHrP: SCC, adenoCA of lung, pancreas, kidney, others. 2. Osteolytic metastases: Breast, MM. 3. Production of calcitriol: HL.
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4
Q

Hypercalcemia related to vitD:

A
  1. Hypervitaminosis D. 2. Granulomatous diseases.
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5
Q

Other relatively common causes of hypercalcemia:

A
  1. Milk-alkali syndrome (chronic renal failure who are taking calcium carbonate). 2. Hyperthyroidism. 3. Thiazides. 4. Falsely elevated serum calcium (2o to increased serum binding protein) –> Hyperalbuminemia + MM.
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6
Q

Primary hyperparathyroidism accounts for more than …% of cases of hypercalcemia in otherwise healthy ambulatory patients.

A

90%.

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7
Q

Nephrolithiasis is seen in …-…% of patients with primary hyperparathyroidism.

A

15-20%.

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8
Q

Other symptoms of primary hyperparathyroidism probably include:

A
  1. Increased frequency of HTN. 2. Gout. 3. Ca pyrophosphate deposition disease.
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9
Q

Besides hypercalcemia, are other effects of PTH (HypoPh, hypercalciuria, hyperphosphaturia) useful in differentiating primary hyperparathyroidism from hypercalcemia of malignancy?

A

Seldom useful.

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10
Q

About …% of patients with primary hyperparathyroidism have normal PTH levels (a finding that is in fact inappropriate given the hypercalcemia).

A

10%. FHH must be excluded.

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11
Q

Indications for surgery:

A
  1. Symptoms of hypercalcemia. 2. Elevated serum Ca >1mg/dL above normal. 3. Cr clearance reduction of 30% compared with age-matched controls. 4. 24h urine Ca>400mg/d. 5. T score <50. 7. Patient preference or patient inability to comply with long term monitoring.
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12
Q

Primary hyperparathyroidism - Monitoring for patients not undergoing surgery:

A
  1. Assessment of symptoms, calcium level, renal function every 6-12months. 2. Bone density screening yearly of the hip, spine, and wrist. 3. Monitoring, possibly radiographically, for development of nephrolithiasis.
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13
Q

Other than primary hyperparathyroidism - DDX of hypercalcemia with elevated PTH:

A
  1. Lithium use. 2. MEN. 3. 2o or 3o hyperparathyroidism. 4. FHH.
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14
Q

FHH - Textbook presentation:

A
  1. Usually made at childhood during evaluation of asymptomatic hypercalcemia or during screening because of a positive family history. 2. Condition may also present during adulthood as hypercalcemia with a normal to slightly elevated PTH.
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15
Q

FHH - Pathogenesis:

A

Makes the Ca sensing receptor, found on various tissues throughout the body, less sensitive to Ca. In the parathyroids this means that higher calcium levels are needed to suppress PTH release.

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16
Q

3 important features to distinguish FHH from primary hyperparathyroidism:

A
  1. Family history. 2. Urinary Ca excretion is reduced (400). 3. Serum Mg is usually increased in FHH. –> Genetic testing is available when the diagnosis is difficult to make.
17
Q

Hypercalcemia of malignancy - Is it common for hypercalcemia to be the presenting symptom of a malignancy?

A

NO.

18
Q

Prognosis of hypercalcemia of malignancy:

A

50% 30-day mortality.

19
Q

MCC of hypercalcemia of malignancy?

A

PTHrP –> Called humoral hypercalcemia of malignancy (HHM).

20
Q

What is the rarest cause of hypercalcemia of malignancy?

A

Hypercalcemia by elaboration of vitD - Seen most commonly with lymphoma.

21
Q

Malignancies that commonly associated with hypercalcemia are in approximate order of frequency?

A
  1. Lung. 2. Breast. 3. MM. 4. Lymphoma. 5. Head/Neck. 6. Renal. 7. Prostate.
22
Q

MM - Symptoms at presentation as reported in a recent study:

A

73% –> Anemia, normocytic, normochromic. 67% –> Lytic lesions on radiograph. 58% –> Bone pain. 19% –> Renal insufficiency. 13% –> Hypercalcemia >11.

23
Q

MM - M component:

A

82% –> Abnormal serum protein electrophoresis. M component most commonly appears in the gamma range and is most commonly IgG. 16% –> Have only free light chains.

24
Q

The diagnosis of MM is based on the identification of:

A
  1. Marrow plasmacytosis (>10%). 2. Lytic bone lesions. 3. A serum or urine M component or both.
25
Q

Milk-Alkali syndrome - Textbook presentation:

A

There can be many presentations of the milk-alkali syndrome. Acute cases are often seen in women who can use calcium carbonate for dyspepsia or osteoporosis who develop hypercalcemia.

26
Q

What is the milk-alkali syndrome?

A
  1. Hypercalcemia. 2. Metabolic alkalosis. 3. Renal insufficiency. caused by the absorption of calcium and an absorbable alkali.
27
Q

Is the milk-alkali syndrome a common cause of hypercalcemia?

A

It is a distant 3rd among the leading causes of hypercalcemia in HOSPITALIZED patients, after malignancy and primary hyperparathyroidism.

28
Q

Hypercalcemia is detected in 1 of 3 clinical circumstances:

A
  1. During routine lab work-ups in asymptomatic patients (most cases). 2. During evaluation of patients with certain findings that suggest hypercalcemia (constipation, weakness, fatigue, depression, nephrolithiasis, osteopenia). 3. Severe hypercalcemia may present as altered mental status.