Hypercalcemia
This chapter examines the clinical and laboratory presentations of hypercalcemia and describes the clinical and laboratory findings that define an emergency situation in elevated serum calcium concentration. The initial approach to emergency treatment of
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Hypercalcemia Robert Klein
Précis 1. Clinical Setting—Hypercalcemia (serum calcium >10.5 mg/dL or ionized calcium level >1.3 mmol/L) is a disorder commonly encountered by primary care physicians and is usually well tolerated if calcium levels remain below 12 mg/dL (ionized calcium level of 1.5 mmol/L). Calcium levels above this threshold are associated with increasingly severe volume contraction, neurological, cardiac, and gastrointestinal dysfunction, and require urgent treatment to prevent life-threatening consequences. 2. Diagnosis—The differential of hypercalcemia is broad and can be categorized based on parathyroid hormone (PTH) levels. The principal challenges in the management of hypercalcemia are distinguishing primary hyperparathyroidism (PHPT) from conditions that will not respond to parathyroidectomy (e.g., cancer, granulomatous disorders, vitamin D intoxications). Correct management depends on an accurate diagnosis. However, in the setting of hypercalcemic crisis, therapy should be initiated immediately, and the diagnosis pursued after the patient’s condition has been stabilized. (a) History—Important complaints include polyuria and altered mental status which together can contribute to volume contraction and worsening hypercalcemia. Calcium levels elevated to the extent that overt symptoms are present nearly always indicates PHPT or malignancy. The most frequent presentation of PHPT is that of relatively “asymptomatic” disease. Constitutional symptoms (fevers, night sweats, weight loss) raise concern for a malignant or infectious etiology. A careful family history should provide
R. Klein, M.D. (*) Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA e-mail: [email protected] L. Loriaux (ed.), Endocrine Emergencies: Recognition and Treatment, Contemporary Endocrinology 74, DOI 10.1007/978-1-62703-697-9_16, © Springer Science+Business Media New York 2014
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clues as to whether the patient has a familial form of hyperparathyroidism or familial hypocalciuric hypercalcemia (FHH). Calcium and vitamin D supplement use or ongoing treatment with a thiazide or lithium represents other obvious causes. (b) Physical Examination—Just as with hypocalcemia, the clinical presentation of hypercalcemia depends on the chronicity and severity of the disturbance—ranging from few if any symptoms with longstanding mild hypercalcemia to severe life-threatening symptoms if an acute and dramatic change has taken place. The term hypercalcemic crisis describes a severely debilitated patient with profound volume depletion, cardiac decompensation, and altered neurocognitive function. This can present as obtundation and even coma. (c) Laboratory Evaluation—Hypercalcemia is defined as a serum calcium >10.5 mg/dL or ionized calcium level >1.3 mmol/L. Once the diagnosis is considered, a repeat measurement (ionized calcium or total serum calcium corrected for albumin) should be obtained to confirm a true increase in the serum calcium concentration. The first
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