Updated: 12/15/2019

Hypercalcemia

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Topic
Introduction
  • An increase in serum calcium level
  • Mechanisms and pathophysiology
    • dietary causes
      • calcium ingestion (milk-alkali syndrome)
      • hypervitaminosis D
      • hypervitaminosis A
    • pharmacologic causes
      • thiazides
        • causes increased distal tubule reabsorption of calcium
        • used to treat hypercalciuria
    • malignancy-associated causes
      • Paget's disease
        • typically does not result in hypercalcemia
        • can be come hypercalcemic if patient is immobilized
      • squamous cell cancer of the lung
        • ectopic production of PTH (PTH related peptide - PTHrP)
      • multiple myeloma
        • production of IL-1 activates osteoclast-driven bone resorption
    • sarcoidosis
      • granulomatous macrophages produce 1α-hydroxylase which produces high amounts of 1,25 vitamin D
    • hyperparathyroid 
    • genetic causes
      • familial hypocalciuric hypercalcemia
        • defect in calcium sensor of parathyroid gland 
          • there is a loss of negative feedback on PTH by hypercalcemia
          • PTH levels are normal to high despite high serum calcium levels
        • urine excretion of calcium is low
          • key feature distinguishing primary hyperparathyroidism from FHH
    • other causes
      • hyperthyroid
      • Addison's disease
      • Zollinger-Ellison syndrome
Presentation
  • Symptoms 
    • CNS
      • confusion
      • stupor
      • weakness
    • gastrointestinal
      • constipation
      • anorexia
      • nausea
      • vomiting
    • kidney
      • polyuria
      • kidney stones
      • polydipsia
  • Physical exam
    • weakness
    • decreased/absent reflexes
  • EKG
    • shortened QTc interval 
Treatment
  • Conservative
    • hydration
      • saline diuresis
  • Pharmacologic
    • loop diuretics
    • bisphosphonates
    • mithramycin
    • calcitonin
    • galium nitrate
  • Other
    • dialysis
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Questions (4)
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(M1.EC.14.75) A 28-year-old African American woman presents to her primary care physician with two weeks of nausea, abdominal pain, and increased urination. She states she has had kidney stones in the past and is concerned because her current pain is different in character from what she had experienced then. In addition she reports increasing weakness and fatigue over the past several months as well as mild shortness of breath. Chest radiography shows bilateral hilar adenopathy. Which of the following processes is most likely responsible for her current symptoms?
Tested Concept

QID: 106742
1

Osteoclast-driven bone resorption

0%

(0/24)

2

Increased production of parathyroid hormone

21%

(5/24)

3

Ectopic parathyroid hormone release

54%

(13/24)

4

Increased intestinal absorption of calcium

17%

(4/24)

5

Increased renal calcium reabsorption

8%

(2/24)

M 1 B

Select Answer to see Preferred Response

(M1.EC.14.91) A 60-year-old man presents to the emergency room with a chief complaint of constipation. His history is also significant for weakness, a dry cough, weight loss, recurrent kidney stones, and changes in his mood. He has a 30 pack-year history of smoking. A chest x-ray reveals a lung mass. Labs reveal a calcium of 14. What is the first step in management? Tested Concept

QID: 104416
1

Begin alendronate

9%

(2/23)

2

Administer calcitonin

22%

(5/23)

3

Begin furosemide

26%

(6/23)

4

Administer intravenous fluids

39%

(9/23)

5

Begin hydrochlorothiazide

4%

(1/23)

M 3 E

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