Chapter 1

Question 1

Regulators of calcium

Answer 1

Bone
GI
Kidneys

Question 2

Stimulators of PTH secretion

Answer 2

decreased serum Ca
Mild decreases in serum magnesium
Increases in serum phosphorus

Question 3

Inhibitors of PTH secretion

Answer 3

Increase in Calcium
Severe decreases in magnesium
Calcitriol

Question 4

how to adjust calcium for albumin

Answer 4

For every 10 below normal for albumin (40), increase serum calcium by 0.2

Question 5

Degrees of hypercalcemia

Answer 5

2.5-3; mild
3-3.5; moderate
>3.5 severe

Question 6

Approach hypercalcemia

Answer 6

PTH vs non PTH mediated
Non PTH mediated;
-CA; humoral vs osteolytic hypercalceia
-Vit D mediated
-Genetic (FHH)

Question 7

Humoral hypercalcemia

Answer 7

PTHrp 
-squamous cell
-adenoCA (breast, ovary)
-RCC
-transitional cell carcinoma (bladder)
**when present likely means high tumor burden since each cell only secretes small amount PTHrp
Calcitriol
-secreted by B cells in lymphoma (less common)

Question 8

Osteolytic hypercalcemia

Answer 8

due to invasion of bone; multiple myeloma, adenoma breast, some lymphomas

Question 9

Vitamin D mediated

Answer 9

-Granulomatous disease; TB, sarcoid
-Endocrine; thyrotoxicosis (increased bone turnover), primary adrenal insufficiency (decrease vascular volume and calcium clearance), phew (produces PTHrp)
-prolonged immobilization
Drugs: thiazide diuretics, lithium, vit D

Question 10

Treatment hypercalcemia

Answer 10

• IVF
• Lasix
• bisphosphonates
• Calcitonin
• steroids

Question 11

Bisphosphonates

Answer 11

inhibits osteoclast effects

• great affinity for bone and resistant to degradation effects which account for their long half life
• poor absorption GI so IV route necessary
• effect begins within 2 days and nadir 7 days
• can last several weeks to months

Question 12

Calcitonin

Answer 12

• inhibits bone resumption and increase real excretion of calcium
• onset 4-6 hours, nadir 12-24 hours
• not as effective as calcium lowering agent as bisphosphonates but is faster onset when dealing with dangerously high levels of calcium (>4)
• tachyphylaxis develops in 48-72 hours

Question 13

Steroids in treatment hypercalcemia

Answer 13

• Only effective if hypercalcemia mediated by hematologic cancers (lymphoma or MM) or granulomatous diseases
• give equivalent of hydrocortisone 2-300 mg/day IV 3-5 days

Question 14

Calcium >3.5 asymptomatic

Answer 14

could use IVF + bisphosphonates vs calcitonin

Question 15

Calcium >3.5 symptomatic

Answer 15

IVF + calcitonin +/- bisphosphontes +/- steroids

Question 16

EKG hypercalcemia

Answer 16

Shortening QT
Osborn (j) waves; positive deflection at J point (also see in hypothermia)
Ventricular irritability and VF arrest

Question 17

EKG hypocalcemia

Answer 17

QT prolongation

Dysrrhythmias uncommon

Question 18

Hypocalcemia values

Answer 18

2. 2-2.6- mild

1. 9-2.2 niderate

Question 19

Sx hypocalcemia

Answer 19

Increased neuromuscular irritability; tetany
Chovstek
Trousseau
Perioral and fingertip parasthesia
Spontaneous muscle cramps
Feared: contraction of respiratory and laryngeal spasm

Question 20

Approach hypocalcemia

Answer 20

PTH abnormalities (low PO4)

• hypoparathyroidism; surgery, radiation, autoimmune (polyglandular autoimmune syndrome, infiltrative
• functional hypopara: Mg deficiency
• PTH resistance; pseudohypoparathyroidism

Vitamin D abnormalities (High PO4)

• Vit D deficiency; nutritional, malabsorption
• Altered vit D metabolism: cirrhosis, CKD

Drugs
-calcitonin, bisphosphonates, plicamycin, loop diuretics

Acute causes: pancreatitis, rhabdomyolysis, tumor lysis syndrome, transfusion blood products (citrate), toxic shock syndrome

Others: malabsorption, hypoalbuminemia

Question 21

Treatment Hypocalcemia (severe)

Answer 21

IV; calcium gluconate preferred over calcium chloride due to less tissue necrosis if extravasated

• 1-2 grams calcium gluonate administered over 10-20 minutes (faster administration can result in prolonged QT)
• Infusion cannot contain bicarb or phosphate because can precipitate into insoluble calcium salts

Question 22

Anti-Ro, Anti-La also known as SS-A and SS-B

Answer 22

Sjogren’s syndrome

Question 23

Anti-Smith

Answer 23

Lupus

• 99% people with autoantibody have disease, but only 20% pts with SLE have anti-smith
• associated with CNS involvement, kidney disease, lung fibrosis and pericarditis but not associated with disease activity

Question 24

Anti-nRP/anti-U1-RNP

Answer 24

Highly associated with mixed connective tissue disease

Question 25

Anti-Scl-70

Answer 25

Scleroderma

• sensitivity for scleroderma is 34%, but higher for diffuse cutaneous involvement (40%)
• specificity 99-100
• found in 5% pts with SLE

Question 26

Anti-Jo1

Answer 26

polymyositis/dermatomyositis
Rarely found in other connective tissue disease
Most associated with ILD
20-40% of polymyositis is positive for anti-Jo

Question 27

Anti-DsDNA

Answer 27

Specific for SLE
Sensitivity 25-85%
Titers correlate with disease activity

Question 28

Anti-histone antibodies

Answer 28

Drug induced lupus 75-95%

Question 29

Anti-gp210
anti-p62
Anti sp100

Answer 29

Primary biliary cirrhosis

Question 30

Anti-centromere antibodies

Answer 30

CREST, PBC, proximal scleroderma

Question 31

Anti-PM-Scl

Answer 31

polymyositis/systemic sclerosis overlap syndrome