Hypercalcemia
Original Editors - Whitney Browning & Natalie Elliott from Bellarmine University's Pathophysiology of Complex Patient Problems project.
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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.
Prevalence[edit | edit source]
Hypercalcemia is a rather common medical emergency. Between 20-40% of patients suffering from cancer develp 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.
Characteristics/Clinical Presentation
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System | Signs/symptoms |
Musculoskeletal |
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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:
- 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]
Medication | 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, vomiting |
Intravenous Biphosphonates | Prevent bone breakdown, reduce bone pain, reduce the number of pathologic fractures | Heartburn, headache, constipation, diarrhea, muscle and joint pain |
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) |
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 gain |
Hemodialysis | Remove excess waste and calcium from the bloodstream | Hypotension, muscle cramps, itching, difficulty sleeping, anemia, pericarditis, hyperkalemia, infection, depression |
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:
- 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).
http://www.the-hospitalist.org/SpringboardWebApp/userfiles/hosp/image
Etiology/Causes[edit | edit source]
Common causes of hypercalcemia include: (mayoclinic)
- 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 simlar 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 laying down or in bed may cause bones to release calcium into the blood due to the lack of weightbearing.
- 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 mutliple systems. Usually, the first signs and symptoms are noticed in the musculoskeletal system causing muscle pain, spasms, or bone pain. However, each patient will present differently depending on the severity and organ system involved.
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)
- 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).
- 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:
- 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
- Ensure adequate hydration
- Quality of life measures
- Strength/ROM
- Patient and Family Education
Alternative/Holistic Management (current best evidence)[edit | edit source]
- Increase fluid intake
- Substitute with sea salt in diet
- Decease consumption of dietary calcuim and Vitamin D
- Avoid pasteurized dairy products, low-fat dairy products, and processed foods high in polyunsaturated fats and low in saturated fats
- Probiotics
Differential Diagnosis[edit | edit source]
- Hyperparathyroidism
- Malignancy
- Sarcoidosis
- Lithium, Salicylate, Theophylline Toxicity
- Thyroid Toxicity
- Vitamin Toxicity
- Tuberculosis
Case Reports/ Case Studies[edit | edit source]
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http://www.aapsus.org/articles/6.pdf
Resources
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American Academy of Family Physicians
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
see adding references tutorial.
1.Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St. Louis, MO: Elsevier Saunders; 2013.
2. Hypercalcemia [Internet]. MayoClinic. 2012 [updated 2012 Aug 10]. Available from:
http://www.mayoclinic.com/health/hypercalcemia/DS00976/DSECTION=causes
3. Diuretics and High Blood Pressure: