Hypercalcaemia DDx

Causes of HYPERcalcaemia

• Nature: Bones, stones, groans and psychic moans
• Usually associated with increased calcium release form bones and impaired renal removal and malignancy
• Causes: >90% from Malignancy and Hyperparathyroidism
  • Basically: Tumour, increased PTH and increased Vitamin D

1. Bone Malignancy
   • breast, lung, thyroid, kidney, prostate, myeloma, leukaemia
   • lymphoma, Hodgkin’s and non-Hodgkin’s
   • Paget’s (non-malignant increased bone turnover)
2. Hyperparathyroidism
   • Normally responds to decreased Ca and increases bone turnover
3. Other
   • endocrine (Addison’s, phaeochromocytoma, hyperthyroidism)
   • dehydration
   • respiratory (Sarcoidosis, TB)
   • drugs (lithium, thiazides, Vitamin D)
4. Fictitious
   • Not corrected level for albumin
   • Prolonged cuff time

Clinical symptoms

• Stones (Renal colic and hypercalcaemic stones)
• Bones (Increased osteolysis and fractures)
• Psychic moans (Depression, confusion, hallucinations and coma)
• Abdominal groans (Anorexia, N, V, constipation, PUD, pancreatitis)
• Other
  • Muscle weakness, malaise, hyporeflexia
  • Confusion, apathy, decreased memory
  • Nephrogenic diabetes insipidus (Polyuria and polydipsia)

Complication

Cardiac Arrhythmia and ECG changes

• QT shortening (Prolonged with low K, Ca, Mg)
• Prolonged PR
• Widened QRS
• Notched QRS with increased voltage
• AV block…..CHB…..cardiac arrest

Correction

Key to treatment is volume expansion

• Promote urinary excretion(if CVS and renal function adequate)
  • Forced saline Diuresis (plus magnesium and potassium) – 300-500ml N saline/hr
  • This replaces lost fluid and forces diuresis
  • Must monitor or replace K and Mg as these will be lost in the urine along with the calcium
  • NOTE do not give THIAZIDES, they will worsen condition
    • Treatment with FRUSEMIDE is controversial as it promotes Calcium bone reuptake
• Haemodialysis
  • Treatment of choice in CVS or renal compromise
• Calcitonin/EDTA bisphosphonates
  • Reduce bone resorption and reduce GIT absorption of Calcium
  • Effect in 48 hours and last 15 days

References and Links

• CCC – Calcium metabolism
• CCC – Calcium basics
• CCC – Hypercalcaemia Overview
• CCC – Hypocalcaemia
• CCC – Calcium replacement (advantages/disadvantages)
• CCC – Calcium as an inopressor

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes