Patient explanation

Gold standard case presentation

Hypercalcaemia

In this case the patient most likely suffers from hypercalcaemia and the question is what the underlying cause is.

Causes of hypercalcaemia

• Hyperparathyroidism
• Bone breakdown from malignancy either primary or secondary
• Sarcoidosis
• Excess calcium intake

Clinical symptoms and signs

• Asymptotic if chronic or acute
• Symptoms if present, often in retrospect (‘stones, groans, and psychic moans’)
  • constipation
  • fatigue
  • myalgia
  • depression
  • confusion
  • symptoms associated with renal and/or gallbladder stones

Investigations

• ECG – for cardiac conduction defects
• Urine for renal dysfunction
• Bloods
  • Full blood count for anaemia
  • Renal function
  • Liver function
  • Calcium, phosphate and vitamin D levels
  • Parathyroid hormone levels
  • Thyroid function tests
  • C-reactive protein
  • Autoimmune antibodies (ANA)
  • PSA – prostate specific antigen
• Ultrasound imaging of parathyroid
• Investigations for underlying malignancy based upon the history e.g. x-ray chest if a heavy smoker

Management

Management depends upon the cause of the hyperglycaemia and whether it is acute it chronic.

Acute hypercalcaemia secondary to malignancy is often a medical emergency:

• Intravenous fluids
• IV or oral bisphosphonates to reduce the calcium levels

In hyperparathyroidism, definitive management is surgical excision of the parathyroids.