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Case #3 Calcium

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Anaesthetics and Critical Care

Obstetrics Gynaecology

Trauma and Orthopaedics

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Urology

Version Jan 2023

A 67 year old lady is seen in ambulatory care. She had blood tests done by her GP as she described some tiredness. Her weight is stable. She has no bowel or bladder or other symptoms. She has no bone pain. Breast screening has been negative. She was found to have calcium of 3.1 mmol/L. She is otherwise well. She has noticed passing more urine and drinking more recently. Clinically she is euvolemic. She is a non-smoker and never smoked. She rarely drinks alcohol. Her past history is only hypertension diagnosed when she was 62. She takes Bendroflumethiazide. Her BP today is 123/78 mmHg. Her blood results are shown below.

Chemistry	Value	Range
Serum Sodium	129	137 - 144 mmol/L
Serum Potassium	4.0	3.5 - 4.9 mmol/L
Serum Chloride	100	95 - 107 mmol/L
Serum Bicarbonate	24	20 - 28 mmol/L
Anion Gap	13	12 - 16 mmol/L
Serum Urea	10.2	2.5 - 7.5 mmol/L
Serum Creatinine	112	60 - 110 micromol/L
Serum corrected Calcium	3.1	2.2 - 2.6 mmol/L
Serum Phosphate	0.7	0.8 - 1.4 mmol/L
Serum Total protein	62	61 - 76 g/L

1. What causes of Hypercalcaemia do you know

Primary hyperparathyroidism
Lung cancer and PTH related peptide release
Myeloma
Sarcoidosis
Medicatons e.g. Vitamin D and Calcium, Thiazides

The majority are either cancer or primary hyperparathyroidism.

2. What tests would you do and why

Tests

Chest X Ray to look for cancer. Look for other clues towards malignancy. Such as evidence of smoking, weight loss and signs of malignancy e.g. clubbing. Hypercalcaemia is associated with the release of PTH related peptide by squamous cell lung cancer.
PTH level is key to diagnosing Primary hyperparathyroidism
Myeloma screen would be warranted if initial tests are unhelpful if ESR is elevated usually above 60 mm/hr or there is bone pain, lytic lesions or nephropathy
Sarcoid: ACE levels may be considered. Clues for sarcoid would a skin rash or bihilar lymphadenopathy seen on CXR

What would you do next

Initial management is rehydration. The calcium level is now 2.8 mmol/L and is generally asymptomatic. I would advise her to ensure she is well hydrated and send her home to await the results through ambulatory care. I would stop any calcium supplements or any drugs that retain calcium. I would bring back in a few days and if calcium is elevated I would give IV Pamidronate or Zoledronate

Her PTH result comes back and is normal. The other tests are also normal. What is the likely diagnosis

An elevated Calcium should suppress PTH levels to almost be undetectable. Sometimes the PTH level is very high but even a normal or high normal PTH is abnormal in the context of hypercalcaemia and the diagnosis is likely to be Primary hyperparathyroidism.

What should be the next step

She should be referred to endocrinology who can assess and refer to surgeons if they feel that consideration for parathyroidectomy is appropriate.

What are complications of the operation

Haemorrhage
Infection
Hypocalcaemia usually transient

7. Question

References

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