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Flashcards in Hypercalcemia Deck (15):
1

Diagnostic algorithm

1. Acute
a. PTH high
->Primary hyperparathyroidism
b. PTH low
->Consider malignancy, PTHrP, clinical evaluation

2. Chronic
a. PTH low
->Granulomatous disease
->Familial hypercalciuric hypercalcemia
->Milk-alkali syndrome
->Medications: lithium, thiazides
->Immobilisation
->Vit D or Vit D intoxication
->Adrenal insufficiency
->Hyperthyroidism
b. PTH high
->Primary, secondary, tertiary
->Consider MEN syndrome

2

Primary hyperPTH: mechanism, clinical presentation, diagnostic criteria, treatment

Elevated PTH= +bone turnover
Solitary adenoma or part of MEN->nephrolithiasis, vomiting, abdominal pain, polydipsia, polyuria, depression, fatigue "stones, bone, and abdominal groans and psychic moans"

+Calcium, +PTH, low phosphate

Medical therapy for symptoms
Surgery for symptoms of hypercalciuria or osteoporosis

3

How does lithium cause hypercalcium

Stimulates PTH production

4

Malignancy-related: mechanism, clinical presentation, diagnostic criteria, treatment

Local destruction of bone
Production of PTHrP

Symptoms of hypercalcemia and of particular cancer

Imaging of bones, PTHrP levels, bone marrow biopsy

Treat tumor and control cancer
Bisphosphonates
Calcitriol

5

Sarcoidosis: mechanism, clinical presentation, diagnostic criteria, treatment

++Vitamin D synthesised in macrophages and lymphocytes
Low PTH elevated Vitamin D

Avoid sunlight, decrease vitamin D and calcium intake
Glucocorticoids if needed

6

Renal insufficiency: mechanism, clinical presentation, diagnostic criteria, treatment

Secondary as a result of partial resistance to PTH effectes
Bone pain, pruritis, ectopic calcification, osteomalacia
+Renal function
Limited dietary phosphate IV calcitriol

7

Overview management of hypercalcemia acute

1. Hydration + loop diuretics
2. Bisphosphonate
3. Calcitonin->while awaiting effect of bisphosphonate
4. Glucocorticoids (effective in cancer-induced, calcitriol mediated)
5. Avoid exacerbating medication
6. Dialysis
7. Treat underlying malignancy

8

Corrected calcium

Add 0.8 mg/dL to the serum total calcium
for every 1 g/dL of albumin level below 4 g/dL

9

Most common etiology (2)

1. Primary hyperparathyroidism

10

Clinical features

GIT: abdominal pain, peptic ulcer, vomiting, constipation
Kidney: polyuria, polydipsia, stones
CNS: psychosis, fatigue, depression
Bones: bone pain

11

Investigations

Total serum calcium
Serum ionised calcium
Serum albumin
CMP, UEC, glucose
Resting ECG->decreased QT
Serum PTH
PTHrP
Serum phosphorus
Calcitriol
25-hydroxyvitamin D

Consider:
Skeletal survey
CXR
Serum electrophoresis
24 hour urinary calcium excretion

12

How does magnesium relate to calcium

Decreased magnesium inhibits PTH->hypocalcemia

13

MEN 1 malignancy

Parathyroid hyperplasia/adenoma
Pancreas endocrine->gastrinoma, insulinoma etc
Pituitary prolactinoma

14

MEN 2 a

Thyroid->meduallry
Adrenal phaeochromocytoma
Parathyroid hyperplasia

15

MEN 2b

Similar to MEN 2a, + mucosal neuromas and marfinoid appearance, no +PTH