Hypercalcemia Harrison

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2000:343:1715-1721. Morice AH. Kastelik JA. Chronic cough in adults. Thorax 2003:58:901-907. Williams SG. Schmidt DK. Redd SC. et al. National Asthma Education and Prevention Program. Key clinical activities for quality asthma care. Recommendations of the National Asthma Education and Prevention Program. MMWR Recomm Rep 2003;52(RR-6): 1-8.

A 63-year-old African-American woman is brought to the emergency room for upper arm pain and swelling following a fall at home. The family has noted that for approximately the past 2 months, the patient has become progressively fatigued and absent-minded, and she has developed loss of appetite and weight loss. She has been getting up to urinate several times per night and complains of thirst; however, a test for diabetes in her doctor's office was negative. This morning, she lost her balance because she felt "lightheaded" and fell, landing on her left arm. Physical examination is notable for an elderly, thin woman in mild distress as a result of pain. She is afebrile, her blood pressure is 110/70 mmHg and heart rate 80 bpm. Her thyroid gland is normal to palpation. Her mucus membranes are somewhat dry and sticky. Heart and lung examinations are normal. and carotid auscultation reveals no bruits. Examination of her extremities is significant only for deformity of the left mid-humerus with swelling. The left radial pulse is 2+ and symmetric. The radiologist calls you to confirm the fracture of the mid-left humerus but also stales that there is the suggestion of some lytic lesions of the proximal humerus and recommends a skull film. Serum creatinine level is 2.1 mg/dL. with normal electrolyte and glucose concentrations. but serum calcium level is 13 mg/dL and hemoglobin level is 9.2 m/dL.

^ What is the most likely diagnosis?

^ What is the most likely underlying etiology in this patient? ^ What is your next therapeutic step?

ANSWERS TO CASE 36: Hypercalcemia/Multiple Myeloma

Summary: A 63-year-old African-American woman is evaluated for a humeral fracture sustained during a fall because of lightheadedness. She has a 2-month history of fatigue, absent-mindedness, loss of appetite and weight, and nocturia. Her vital signs are normal. Her thyroid gland is normal to palpation. Her mucus membranes are somewhat dry and sticky. In addition to the fracture seen on x-ray, she also has lytic lesions of the proximal humerus. She has renal insufficiency, anemia, and hypercalcemia.

♦ Most likely diagnosis: Hypercalcemia with pathologic fracture of the left humerus.

+ Most likely underlying etiology: Multiple myeloma.

+ Next therapeutic step: Initial therapy of the hypercalcemia with IV fluids could be started in the emergency room.

Analysis

Objectives

1. Know the clinical presentation and differential diagnosis of hypercalcemia.

2. Know the treatment of symptomatic hypercalcemia.

Considerations

The patient presents with acute confusion, fatigue, and lethargy, all symptoms of hypercalcemia, consistent with the calcium level of 13 mg/dL. The first step in therapy should be intravenous hydration. An ECG is important because hypercalcemia may lead to cardiac arrhythmias. A focused diagnostic strategy should focus on the possibility of hyperparathyroidism and malignancy, including multiple myeloma. Given the rapidity of onset of symptoms, weight loss, age, and presence of lytic bone lesions, the first concern should be for malignancy, such as multiple myeloma, or bony metastases from an undiagnosed cancer. A skull x-ray would be helpful if it shows lytic bone lesions. Both serum and urine electrophoresis would help to identify the presence of a monoclonal gammopathy. Normal serum parathyroid hormone (PTH) and parathyroid hormone-related protein (PTHrP) levels would exclude other causes of hypercalcemia (diagnostic algorithm is given in Figure 36-1 and causes of hypercalcemia in Table 36-1). Treatment then can be aimed at etiology (Table 36-2).

Hypercalcemia And Diagnostic Algorithm

Figure 36-1. Algorithm for evaluation of patients with hypercalcemia. FHH = familial hypocalciuric hypercalcemia; MEN = multiple endocrine neoplasia; PTH = parathyroid hormone; PTHrP = parathyroid hormone-related protein, f Reproduced, with permission, from Potts JT. Diseases of the parathyroid gland and other hyper- and hypocalcemia disorders. In: Braunwald E, Fauci AS, Kasper DL. et al. eds. Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill. 2005:2260.)

Figure 36-1. Algorithm for evaluation of patients with hypercalcemia. FHH = familial hypocalciuric hypercalcemia; MEN = multiple endocrine neoplasia; PTH = parathyroid hormone; PTHrP = parathyroid hormone-related protein, f Reproduced, with permission, from Potts JT. Diseases of the parathyroid gland and other hyper- and hypocalcemia disorders. In: Braunwald E, Fauci AS, Kasper DL. et al. eds. Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill. 2005:2260.)

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