Hypercalcemia: Difference between revisions
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The incidence of hyperparathyroidismis considerably higher in women, thus suggesting women are at greater risk of developing hypercalcemia. The annual incidence in women older than 65 years is 250 per 100,000, although elevations in calcium levels related to cancer have no sex predominance. Also, with an increase in age, the incidence of hyperparathyroidism rises just as the rate of malignancy and the malignancy-associated hypercalcemia increases as well.<ref name="2" /> | The incidence of hyperparathyroidismis considerably higher in women, thus suggesting women are at greater risk of developing hypercalcemia. The annual incidence in women older than 65 years is 250 per 100,000, although elevations in calcium levels related to cancer have no sex predominance. Also, with an increase in age, the incidence of hyperparathyroidism rises just as the rate of malignancy and the malignancy-associated hypercalcemia increases as well.<ref name="2" /> | ||
== Characteristics/Clinical Presentation<br> == | == Characteristics/Clinical Presentation<br> == | ||
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== Associated Co-morbidities == | == Associated Co-morbidities == | ||
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'''Musculoskeletal<ref name="12" />''' | '''Musculoskeletal<ref name="12" />''' | ||
*Hypercalcemia of malignancy can result from osteolytic metastases or humerally mediated bone resorption. | *Hypercalcemia of malignancy ([[Multiple_Myeloma|multiple myeloma]]) can result from osteolytic metastases or humerally mediated bone resorption. | ||
*Secondary fractures, skeletal deformities, and/or pain may be symptoms present. | *Secondary fractures, skeletal deformities, and/or pain may be symptoms present. | ||
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*Probiotics | *Probiotics | ||
<ref name="11">Hypercalcemia, causes, symptoms, remedies [Internet]. Growyouthful.com. 2013. Available from:fckLRfckLRhttp://growyouthful.com/ailment/hypercalcemia-high-calcium.php</ref> | <ref name="11">Hypercalcemia, causes, symptoms, remedies [Internet]. Growyouthful.com. 2013. Available from:fckLRfckLRhttp://growyouthful.com/ailment/hypercalcemia-high-calcium.php</ref> | ||
== Differential Diagnosis == | == Differential Diagnosis == |
Revision as of 17:19, 8 April 2013
Original Editors - Whitney Browning & Natalie Elliott from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Lead Editors - Your name will be added here if you are a lead editor on this page. Read more.
Definition/Description
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Hypercalcemia is characterized by elevated calcium levels in the blood. It may include symptoms associated with the musculoskeletal, neurological, cardiovascular, and gastrointestinal systems. Hypercalcemia is often a sign or symptom of other disease occurring within the body. Normal calcium levels range from 8.2-10.2 mg/dL. Mild hypercalcemia occurs when this level raises to 12mg/dL and severe hypercalcemia is classified as serum calcium at 14mg/dL.Cite error: Invalid <ref>
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Prevalence[edit | edit source]
Hypercalcemia is a common medical emergency and between 20-40% of patients suffering from cancer can develop this during the course of their disease. It is considered the most common serious electrolyte presenting in adults with malignancies. This disorder often occurs in cases of metastatic bone disease with osteolytic lesion, breast cancer and myeloma. This is related to an increase in bone resorption caused by tumor cell production of parathyroid hormone-related protein that stimulates osteoclasts. It is also associated with primary hyperparathyroidism which occurs in 25 per 100,000 individuals and 75 per 100,000 hospitalized patients. This condition is the most common cause of mild hypercalcemia and can be treated through outpatient care. More than 50,000 cases occur in the U.S. each year. Cite error: Invalid <ref>
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The incidence of hyperparathyroidismis considerably higher in women, thus suggesting women are at greater risk of developing hypercalcemia. The annual incidence in women older than 65 years is 250 per 100,000, although elevations in calcium levels related to cancer have no sex predominance. Also, with an increase in age, the incidence of hyperparathyroidism rises just as the rate of malignancy and the malignancy-associated hypercalcemia increases as well.Cite error: Invalid <ref>
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Characteristics/Clinical Presentation
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System | Signs/symptoms |
Musculoskeletal |
|
Central Nervous System |
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Gastrointenstinal
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Cardiovascular |
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Associated Co-morbidities[edit | edit source]
Hypercalcemia can lead to many other complications such as:Cite error: Invalid <ref>
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- Osteoporosis: if the bones continue to release calcium into the blood, it could lead to this disease.
- Kidney stones: this could be caused by too much calcium accumulation in the urine, leading to crystal formation in the kidneys.
- Kidney failure: Severe hypercalcemia can lead to damage in the kidneys and possibly cause permanent loss of kidney function.
- Nervous system deficits: Severe hypercalcemia can lead to dementia and confusion.
- Arrythmias: Hypercalcemia can affect the electrical impulses of cardiac muscle, causing irregular heartbeats.
- Primary Hyperparathyroidism: This is often associated with hypercalcemia because it causes an increased release of parathyroid hormone (PTH) which raises serum calcium levels.
Medications[edit | edit source]
MedicationCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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Treatment Effect | Side Effects |
Loop Diuretics (ex; furosemide) | Flushes out excess calcium from system | Frequent urination, arrythmias, electrolyte imbalances, dizziness, muscle cramps/weakness, extreme fatigue, blurred vision, confusion, headache, dehydration, fever, sore throat, cough, skin rash, loss of appetite, nausea, vomitingCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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Intravenous Biphosphonates | Prevent bone breakdown, reduce bone pain, reduce the number of pathologic fractures | Heartburn, headache, constipation, diarrhea, muscle and joint painCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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Calcitonin | Reduce bone reabsorption and slow bone loss | Warmth/redness of the skin, itching of the skin, nausea, loss of appetite, stomach pain, vomiting, skin rash, increased urination, eye pain, swelling in the feet, swelling or irritation at injection site (if injection was given)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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Glucocorticoids | Help to counter the effect of excess Vitamin D | Elevated pressure in the eyes, fluid retention that may cause swelling in the legs, increased blood pressure, mood swings, weight gainCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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Hemodialysis | Remove excess waste and calcium from the bloodstream | Hypotension, muscle cramps, itching, difficulty sleeping, anemia, pericarditis, hyperkalemia, infection, depressionCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]
Hypercalcemia is diagnosed by blood tests revealing increased serum calcium levels. However, other tests may need to be done in order to determine the underlying cause of hypercalcemia. These may include: Cite error: Invalid <ref>
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- Chest X-Ray
- CT Scan
- MRI
- Mammogram
These tests may help determine whether you have lung cancer, breast cancer, other malignancies, or sarcoidosis (a granulomatous disease of the lungs). Cite error: Invalid <ref>
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http://www.the-hospitalist.org/SpringboardWebApp/userfiles/hosp/image
Etiology/Causes[edit | edit source]
Common causes of hypercalcemia include: Cite error: Invalid <ref>
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- Overactivity of parathyroid glands
- Cancer-specifically lung and breast cancer as well as multiple myeloma can increase the risk of hypercalcemia. This is considered to be due to the fact that some malignant tumors can produce a protein that acts similar to the parathyroid hormone which stimulates the release of calcium from the bones into the bloodstream.
- Other disease effects-some people with cancer that causes them to spend increased time lying down or in bed may cause bones to release calcium into the blood due to the lack of weight-bearing.
- Medications-Lithium, a drug used to treat bipolar disorder, may increase the release of parathyroid hormone and cause hypercalcemia. Also, Thiazie diuretics can cause elevated calcium levels by decreasing the amount of calcium excreted in the urine.
- Supplements-eating or drinking too much calcium or Vitamin D
- Dehydration-less fluid in your blood causes the calcium levels to increase
Systemic Involvement[edit | edit source]
As stated in the chart above, hypercalcemia can present with symptoms in multiple systems. Usually, the first signs and symptoms are noticed in the nervous/musculoskeletal system causing some kind of muscle pain, weakness, and/or dysfunction. However, each patient will present differently depending on the severity and organ system involved. Cite error: Invalid <ref>
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The primary systems effects and the mechanisms of involvement are described below:
NeurologicalCite error: Invalid <ref>
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- Increased calcium levels decrease neuromuscular excitability, which leads to hypotonicity in smooth and striated muscle.
- Neuromuscular symptoms include weakness and diminished deep-tendon reflexes.
- Muscle strength is impaired, and respiratory muscular capacity may be decreased.
- Central nervous system impairment may portray as delirium, personality change, cognitive dysfunction, disorientation, hallucinations and delusions.
- Has been documented to increase cerebrospinal fluid protein, which may be associated with headache
CardiovascularCite error: Invalid <ref>
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- Associated with increased myocardial contractility and irritability.
- Electrocardiographic changes are characterized by slowed conduction, including prolonged P-R interval, widened QRS complex, shortened Q-T interval, shortened or absent S-T segments.
- Incomplete or complete atrioventricular block may develop and progress to complete heart block, a systole, and/or cardiac arrest.
GastrointestinalCite error: Invalid <ref>
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- Symptoms related to the depressive action of hypercalcemia on the autonomic nervous system, resulting smooth-muscle hypotonicity.
- Increased gastric acid secretion often accompanies hypercalcemia.
- Anorexia, nausea, and vomiting are made worse by increased gastric residual volume.
- Constipation is worse due to dehydration associated with hypercalcemia.
- Abdominal pain may progress to obstipation (can be confused with acute abdominal obstruction).
RenalCite error: Invalid <ref>
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- Loss of urinary concentrating ability and polyuria due to tubular defect in the kidney.
- Decreased fluid intake and polyuria lead to symptoms associated with dehydration.
- Decreased reabsorption of sodium, magnesium, and potassium occur as a result of salt and water depletion
- Renal insufficiency may occur as a result of diminished glomerular filtration.
MusculoskeletalCite error: Invalid <ref>
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- Hypercalcemia of malignancy (multiple myeloma) can result from osteolytic metastases or humerally mediated bone resorption.
- Secondary fractures, skeletal deformities, and/or pain may be symptoms present.
Medical Management (current best evidence)[edit | edit source]
Mild Hypercalcemia (defined as corrected total serum calcium level lower than 12 mg/dL (<6 mEq/L or 3.0 mmol/L)Cite error: Invalid <ref>
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- Hydration (IV fluids) followed by observation; this option should be considered for asymptomatic patients who are about to be treated for tumors that are likely to respond to antineoplastic treatment (ex: lymphoma, breast cancer, ovarian cancer, head and neck carcinoma, and multiple myeloma).
- Additional interventions should be directed toward controlling nausea and vomiting, encouraging mobility, noting febrile episodes.
- Minimal use of sedating medications.
Moderate to Severe Hypercalcemia (defined as corrected total serum calcium equal to 12 to 14 mg/dL (6–7 mEq/L or 3.0–3.5 mmol/L)Cite error: Invalid <ref>
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- Rehydration is the essential first step replenishing extracellular fluid, restoring intravascular volume, and saline diuresis
- Hypocalcemic agents
- Moderate doses of furosemide (20–40 mg every 12 hours) increase saline-induced urinary calcium excretion and are useful in preventing or managing fluid overload in adequately rehydrated patients.
- Surgery; resulting from primary hyperparathyroidism, urgent parathyroidectomey.
Prevention
Preventive measures include:Cite error: Invalid <ref>
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- Ensuring adequate fluid intake of 3 to 4 L (100–140 fl oz per day if not contraindicated)
- Salt intake
- Nausea and vomiting control
- Encouraging patient mobility
- Attention to febrile episodes
- Cautious use or elimination of drugs that may complicate management ( ex: drugs that inhibit urinary calcium excretion or decrease renal blood flow, contain calcium, vitamin D, vitamin A, or other retinoids)
Physical Therapy Management (current best evidence)[edit | edit source]
- Weightbearing exercises to prevent osteoporosis and immobility
- Prevention of fractures
- Ensure adequate hydration
- Quality of life measures
- Strength/ROM
- Patient and Family Education
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Alternative/Holistic Management (current best evidence)[edit | edit source]
- Increase fluid intake
- Substitute with sea salt in diet
- Decease consumption of dietary calcium and Vitamin D
- Avoid pasteurized dairy products, low-fat dairy products, and processed foods high in polyunsaturated fats and low in saturated fats
- Probiotics
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Differential Diagnosis[edit | edit source]
Evaluation of a patient should include: history, physical examination focusing on clinical manifestations of hypercalcemia, risk factors for malignancy, causative medications, and a family history of hypercalcemia-associated conditions to help clinically determine effectively and accurately a differential diagnosis. Cite error: Invalid <ref>
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- Hyperparathyroidism
- Malignancy
- Sarcoidosis
- Lithium, Salicylate, Theophylline Toxicity
- Thyroid Toxicity
- Vitamin Toxicity
- Tuberculosis
Prognosis:
The prognosis of patients with hypercalcemia depends upon the etiology of the elevation:Cite error: Invalid <ref>
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- Prognosis is very poor with malignancy that has progressed into development of hypercalcemia.
- Prognosis is excellent when the underlying cause is treatable and treatment is initiated promptly.
Case Reports/ Case Studies
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http://www.aapsus.org/articles/6.pdf
http://annonc.oxfordjournals.org/content/11/1/97.full.pdf
Resources
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American Academy of Family Physicians
Recent Related Research (from Pubmed)
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References
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see adding references tutorial.