Internal Medicine

0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:13

Hypercalcemia 739

■Short duration of hypercalcemia (weeks to months) in malignancy-

associated hypercalcemia (MAH)

■Longer duration in primary hyperparathyroidism (HPTH)

■90% with MAH dead in 3 mo

■Pancreatitis, fractures, renal stones – seen in HPTH

■Family history of hypercalcemia – present in MEN-1, familial benign

hypercalcemia (FBH)

■Drugs: thiazides, lithium, vitamin D or A

■Granulomatous disease: sarcoid, TB, coccidioidomycosis, histoplas-

mosis, cryptococcosis

■Thyrotoxicosis: weight loss, tremor, palpitations, thyroid enlarge-

ment

Signs & Symptoms

■General – hypercalcemia: if severe, dehydration, tachycardia,

hypotension; abdominal pain; poor memory and concentration,

depression, stupor, coma

■HPTH: band keratopathy, hypertension, itching, fractures, osteitis

fibrosa cystica (rare)

■Cancer: dehydration, clinically evident tumor burden, bone lesions

and pain (especially myeloma, osseous metastases)

■Granulomatous disease: dyspnea, cough, abnormal chest exam,

lymphadenopathy

tests

Laboratory

■Blood

➣HPTH: elevated Ca, low or normal P, elevated intact PTH

➣Cancer (majority-humoral): elevated Ca, low or normal P, sup-

pressed PTH, elevated PTH-rP

➣Cancer (minority-bone metastases): elevated Ca, suppressed

intact PTH and PTHrP

➣Lymphoma (rare): elevated Ca, P, and 1,25-(OH) 2 vitamin D; sup-

pressed PTH and PTHrP

➣Myeloma: anemia, elevated Ca, suppressed PTH, low PTHrP

(most cases) monoclonal spike in SPEP

➣Thyrotoxicosis: elevated Ca, high normal P, suppressed PTH and

TSH, elevated T4 and/or T3

➣Granulomatous disease: elevated Ca, P, and 1,25-(OH) 2 vitamin

D, suppressed PTH and PTHrP