Hypercalcaemia

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Hypercalcaemia
Ca-TableImage.png
Calcium within the periodic table
Classification and external resources
Specialty Endocrinology
ICD-10 E83.5
ICD-9-CM 275.42
DiseasesDB 6196
MedlinePlus 000365
eMedicine med/1068 emerg/260 ped/1062
Patient UK Hypercalcaemia
MeSH D006934

Hypercalcaemia, also spelled hypercalcemia, is a high calcium (Ca2+) level in the blood serum.[1][2] The normal range is 2.1–2.6 mmol/L (8.8–10.7 mg/dL, 4.3–5.2 mEq/L) with levels greater than 2.6 mmol/L defined as hypercalcemia.[3][4][2] Those with a mild increase that has developed slowly typically have no symptoms.[2] In those with greater levels or rapid onset, symptoms may include abdominal pain, bone pain, confusion, depression, weakness, kidney stones, or an abnormal heart rhythm including cardiac arrest.[3][2]

Most cases are due to primary hyperparathyroidism or cancer.[2] Other causes include sarcoidosis, tuberculosis, Paget disease, multiple endocrine neoplasia (MEN), vitamin D toxicity, familial hypocalciuric hypercalcaemia, and certain medications such as lithium and hydrochlorothiazide.[3][1][2] Diagnosis should generally include either a corrected calcium or ionized calcium level and be confirmed after a week.[2] Specific changes may be seen on an electrocardiogram (ECG).[3]

Treatment may include intravenous fluids, furosemide, calcitonin, or pamidronate in addition to treating the underlying cause.[3][2] The evidence for furosemide; however, is poor. In those with very high levels hospitalization may be required. Hemodialysis may be used in those who do not respond to other treatments. In those with vitamin D toxicity steroids may be useful. Hypercalcemia is relatively common. Primary hyperparathyroidism occurs in between one and seven per thousand people and hypercalcemia occurs in about 2.7% of those with cancer.[2]

Signs and symptoms[edit]

The neuromuscular symptoms of hypercalcemia are caused by a negative bathmotropic effect due to the increased interaction of calcium with sodium channels. Since calcium blocks sodium channels and inhibits depolarization of nerve and muscle fibers, increased calcium raises the threshold for depolarization.[5] There is a general mnemonic for remembering the effects of hypercalcaemia: "Stones, Bones, Groans, Thrones and Psychiatric Overtones"

  • Stones (renal or biliary)
  • Bones (bone pain)
  • Groans (abdominal pain, nausea and vomiting)
  • Thrones (polyuria) resulting in dehydration
  • Psychiatric overtones (Depression 30–40%, anxiety, cognitive dysfunction, insomnia, coma)

Other symptoms can include fatigue, anorexia, and pancreatitis.[citation needed] Limbus sign seen in eye due to hypercalcemia.

Hypercalcemia can result in an increase in heart rate[6] and a positive inotropic effect (increase in contractility).

Symptoms are more common at high calcium blood values (12.0 mg/dL or 3 mmol/l).[citation needed] Severe hypercalcaemia (above 15–16 mg/dL or 3.75–4 mmol/l) is considered a medical emergency: at these levels, coma and cardiac arrest can result. The high levels of calcium ions decrease the neuron membrane permeability to sodium ions, thus decreasing the excitability, which leads to hypotonicity of smooth and striated muscle. This explains the fatigue, muscle weakness, low tone and sluggish reflexes in muscle groups. The sluggish nerves also explain drowsiness, confusion, hallucinations, stupor and / or coma. In the gut this causes constipation. Hypocalcaemia causes the opposite by the same mechanism.

Causes[edit]

Primary hyperparathyroidism and malignancy account for about 90% of cases of hypercalcaemia.[7][8]

Parathyroid function[edit]

Cancer[edit]

Micrograph of ovarian small cell carcinoma of the hypercalcemic type. H&E stain.

Vitamin-D disorders[edit]

High bone-turnover rates[edit]

Kidney failure[edit]

Diagnosis[edit]

ECG changes[edit]

An Osborn wave, an abnormal EKG tracing that can be associated with hypercalcemia.

Abnormal heart rhythms can also result, and ECG findings of a short QT interval[15] suggest hypercalcaemia. Significant hypercalcaemia can cause ECG changes mimicking an acute myocardial infarction.[16] Hypercalcaemia has also been known to cause an ECG finding mimicking hypothermia, known as an Osborn wave.[17]

Treatments[edit]

The goal of therapy is to treat the hypercalcaemia first and subsequently effort is directed to treat the underlying cause.

Fluids and diuretics[edit]

Initial therapy:

  • hydration, increasing salt intake, and forced diuresis.
    • hydration is needed because many patients are dehydrated due to vomiting or renal defects in concentrating urine.
    • increased salt intake also can increase body fluid volume as well as increasing urine sodium excretion, which further increases urinary potassium excretion.
    • after rehydration, a loop diuretic such as furosemide can be given to permit continued large volume intravenous salt and water replacement while minimizing the risk of blood volume overload and pulmonary oedema. In addition, loop diuretics tend to depress renal calcium reabsorption thereby helping to lower blood calcium levels
    • can usually decrease serum calcium by 1–3 mg/dL within 24 h
    • caution must be taken to prevent potassium or magnesium depletion

Bisphosphonates and calcitonin[edit]

Additional therapy:

  • bisphosphonates are pyrophosphate analogues with high affinity for bone, especially areas of high bone-turnover.
    • they are taken up by osteoclasts and inhibit osteoclastic bone resorption
    • current available drugs include (in order of potency): (1st gen) etidronate, (2nd gen) tiludronate, IV pamidronate, alendronate (3rd gen) zoledronate and risedronate
    • all patients with cancer-associated hypercalcaemia should receive treatment with bisphosphonates since the 'first line' therapy (above) cannot be continued indefinitely nor is it without risk. Further, even if the 'first line' therapy has been effective, it is a virtual certainty that the hypercalcaemia will recur in the patient with hypercalcaemia of malignancy. Use of bisphosphonates in such circumstances, then, becomes both therapeutic and preventative
    • patients in renal failure and hypercalcaemia should have a risk-benefit analysis before being given bisphosphonates, since they are relatively contraindicated in renal failure.
  • Calcitonin blocks bone resorption and also increases urinary calcium excretion by inhibiting renal calcium reabsorption
    • Usually used in life-threatening hypercalcaemia along with rehydration, diuresis, and bisphosphonates
    • Helps prevent recurrence of hypercalcaemia
    • Dose is 4 Units per kg via subcutaneous or intramuscular route every 12 hours, usually not continued indefinitely

Other therapies[edit]

Hypercalcaemic crisis [edit]

A hypercalcaemic crisis is an emergency situation with a severe hypercalcaemia, generally above approximately 14 mg/dL (or 3.5 mmol/l).[18]

The main symptoms of a hypercalcaemic crisis are oliguria or anuria, as well as somnolence or coma.[19] After recognition, primary hyperparathyroidism should be proved or excluded.[19]

In extreme cases of primary hyperparathyroidism, removal of the parathyroid gland after surgical neck exploration is the only way to avoid death.[19] The diagnostic program should be performed within hours, in parallel with measures to lower serum calcium.[19] Treatment of choice for acutely lowering calcium is extensive hydration and calcitonin, as well as bisphosphonates (which have effect on calcium levels after one or two days).[20]

Other animals[edit]

Research has led to a better understanding of hypercalcemia in non-human animals. Often the causes of hypercalcemia have a correlation to the environment in which the organisms live. Hypercalcemia in house pets is typically due to disease, but other cases can be due to accidental ingestion of plants or chemicals in the home.[21] Outdoor animals commonly develop hypercalcemia through vitamin D toxicity from wild plants within their environments.[22]

Household pets[edit]

Household pets such as dogs and cats are found to develop hypercalcemia. It is less common in cats, and many feline cases are idiopathic.[21] In dogs, lymphosarcoma, addison’s disease, primary hyperparathyroidism, and chronic renal failure are the main causes of hypercalcemia, but there are also environmental causes usually unique to indoor pets.[21] Ingestion of small amounts of calcipotriene found in psoriasis cream can be fatal to a pet.[23] Calcipotriene causes a rapid rise in calcium ion levels.[23] Calcium ion levels can remain high for weeks if untreated and lead to an array of medical issues.[23] There are also cases of hypercalcemia reported due to dogs ingesting rodenticides containing a chemical similar to calcipotriene found in psoriasis cream.[23] Additionally, ingestion of household plants is a cause of hypercalcemia. Plants such as Cestrum diurnum, and Solanum malacoxylon contain ergocalciferol or cholecalciferol which cause the onset of hypercalcemia.[21] Consuming small amounts of these plants can be fatal to pets. Observable symptoms may develop such as polydipsia, polyuria, extreme fatigue, or constipation.[21]

Outdoor animals[edit]

Trisetum flavescens (yellow oat grass)

In certain outdoor environments, animals such as horses, pigs, cattle, and sheep experience hypercalcemia commonly. In southern Brazil and Mattewara India, approximately 17 percent of sheep are affected, with 60 percent of these cases being fatal.[22] Many cases are also documented in Argentina, Papua-New Guinea, Jamaica, Hawaii, and Bavaria.[22] These cases of hypercalcemeia are usually caused by ingesting Trisetum flavescens before it has dried out.[22] Once Trisetum flavescens is dried out, the toxicity of it is diminished.[22] Other plants causing hypercalcemia are Cestrum diurnum, Nierembergia veitchii, Solanum esuriale, Solanum torvum, and Solanum malacoxylon.[22] These plants contain calcitriol or similar substances that cause rises in calcium ion levels.[22] Hypercalcemia is most common in grazing lands at altitudes above 1500 meters where growth of plants like Trisetum flavescens is favorable.[22] Even if small amounts are ingested over long periods of time, the prolonged high levels of calcium ions have large negative effects on the animals.[22] The issues these animals experience are muscle weakness, and calcification of blood vessels, heart valves, liver, kidneys, and other soft tissues, which eventually can lead to death.[22]

See also[edit]

References[edit]

  1. ^ a b "Hypercalcemia - National Library of Medicine". PubMed Health. Retrieved 27 September 2016. 
  2. ^ a b c d e f g h i Minisola, S; Pepe, J; Piemonte, S; Cipriani, C (2 June 2015). "The diagnosis and management of hypercalcaemia.". BMJ (Clinical research ed.). 350: h2723. PMID 26037642. 
  3. ^ a b c d e Soar, J; Perkins, GD; Abbas, G; Alfonzo, A; Barelli, A; Bierens, JJ; Brugger, H; Deakin, CD; Dunning, J; Georgiou, M; Handley, AJ; Lockey, DJ; Paal, P; Sandroni, C; Thies, KC; Zideman, DA; Nolan, JP (October 2010). "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.". Resuscitation. 81 (10): 1400–33. PMID 20956045. 
  4. ^ Pathy, M.S. John (2006). Principles and practice of geriatric medicine (4. ed. ed.). Chichester [u.a.]: Wiley. p. Appendix. ISBN 9780470090558. 
  5. ^ Armstrong, C.M., Cota, Gabriel.; Cota (1999). "Calcium block of Na+ channels and its effect on closing rate". Proceedings of the National Academy of Sciences of the United States of America. 96 (7): 4154–4157. Bibcode:1999PNAS...96.4154A. doi:10.1073/pnas.96.7.4154. PMC 22436Freely accessible. PMID 10097179. 
  6. ^ http://www.heartandmetabolism.com/download/30/7.pdf
  7. ^ Table 20-4 in: Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology. Philadelphia: Saunders. ISBN 1-4160-2973-7.  8th edition.
  8. ^ Tierney, Lawrence M.; McPhee, Stephen J.; Papadakis, Maxine A. (2006). Current Medical Diagnosis and Treatment 2007 (Current Medical Diagnosis and Treatment). McGraw-Hill Professional. p. 901. ISBN 0-07-147247-9. 
  9. ^ Online Mendelian Inheritance in Man (OMIM) 146200
  10. ^ Online Mendelian Inheritance in Man (OMIM) 145980
  11. ^ Online Mendelian Inheritance in Man (OMIM) 145981
  12. ^ Online Mendelian Inheritance in Man (OMIM) 600740
  13. ^ Non-Small Cell Lung Cancer~clinical at eMedicine.
  14. ^ Online Mendelian Inheritance in Man (OMIM) 143880
  15. ^ http://lifeinthefastlane.com/ecg-library/basics/hypercalcaemia/
  16. ^ Wesson, L; Suresh, V; Parry, R (2009). "Severe hypercalcaemia mimicking acute myocardial infarction". Clinical Medicine. London. 9 (2): 186–7. doi:10.7861/clinmedicine.9-2-186. PMID 19435131. 
  17. ^ Serafi S, Vliek C, Taremi M (2011) "Osborn waves in a hypothermic patient" The Journal of Community Hospital Internal Medicine Perspectives http://www.jchimp.net/index.php/jchimp/article/view/10742/html
  18. ^ Hypercalcemia in Emergency Medicine at Medscape. Author: Robin R Hemphill. Chief Editor: Erik D Schraga. Retrieved April 2011
  19. ^ a b c d Ziegler R (February 2001). "Hypercalcemic crisis". J. Am. Soc. Nephrol. 12 Suppl 17: S3–9. PMID 11251025. 
  20. ^ Page 394 in: Roenn, Jamie H. Von; Ann Berger; Shuster, John W. (2007). Principles and practice of palliative care and supportive oncology. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-9595-8. 
  21. ^ a b c d e Hypercalcemia in Dogs and Cats Peterson DVM, DACVIM. M. E., July 2013. Hypercalcemia in Dogs and Cats. The Merck Veternary Manual. Merck Sharp & Dohme, Whitehouse Station, NJ, USA.
  22. ^ a b c d e f g h i j Enzootic Calcinosis Gruenberg MS, PhD, DECAR DECBHM. W.G., April 2014. Enzootic Calcinosis. The Merck Veternary Manual. Merck Sharp & Dohme, Whitehouse Station, NJ, USA.
  23. ^ a b c d Topical Agents (Toxicity) Khan DVM, MS, PhD, DABVT, S.A., March 2012. Topical Agents (Toxicity). The Merck Veternary Manual. Merck Sharp & Dohme, Whitehouse Station, NJ, USA.