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Case #2 Calcium

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Anaesthetics and Critical Care

Obstetrics Gynaecology

Trauma and Orthopaedics

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Urology

Version Jan 2023

A 72-year-old lady who is a former shopworker presents through the emergency department with breathlessness and malaise over the past 4 weeks. She is dehydrated. She has lost 5 kg in weight in one month. She has been a smoker since her teens approximately 55 pack years. She continues to smoke. Her blood tests are as follows

Chemistry	Value	Range
Serum Sodium	145	137 - 144 mmol/L
Serum Potassium	4.0	3.5 - 4.9 mmol/L
Serum Chloride	100	95 - 107 mmol/L
Serum Urea	15	2.5 - 7.5 mmol/L
Serum Creatinine	120	60 - 110 micromol/L
Serum corrected Calcium	3.4	2.2 - 2.6 mmol/L
Serum Phosphate	0.7	0.8 - 1.4 mmol/L

1. What test would you like next

There is a right upper zone opacity

2. How would you manage her hypercalcaemia

Initially rehydration would be the treatment of choice. She would need at least 3-4 L of fluids in the first 24 hours and then recheck the calcium level. Once she has been rehydrated and if renal function improved then an infusion of IV Pamidronate or Zoledronate in the next few days would be appropriate.

3. What is the mechanism of the high calcium

She likely has a PTH related peptide being secreted by the lung tumour which is classically a non-small cell lung cancer squamous cell and this therefore raised calcium levels.

4. What further tests would you arrange

We need more information to make a diagnosis of lung cancer and that would include a staging CT scan of chest and abdomen and a bronchoscopy. It is always important to get a confirmatory tissue biopsy where possible. The CT scan confirms a right upper zone mass with some spread to hilar lymph nodes. A biopsy confirms squamous cell cancer.

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