Thank you, Brett, for presenting a case of an elderly female with recent treatment for community acquired pneumonia, with ongoing shortness of breath and fatigue found to have severe hypercalcemia.
- Appendectomy is curative for most small appendiceal carcinoid tumors.
- We reviewed the diagnostic approach to hypercalcemia. Management is summarized below as well.
- While waiting for your PTH to come back, you can look at the chloride to phosphate ratio to get a clue about whether hypercalcemia is PTH-independent. Remember that PTH will increase phosphaturia, thus resulting in a high chloride to phosphate ratio. If the ratio is <35, suggests process is PTH INDEPENDENT!
Check out this great review of diagnosis and management from the BMJ.
Diagnostic Approach to Hypercalcemia
Management of Hypercalcemia
- IVF – restore intravasc volume, increase urine ca excretion
- Calcitonin – inhibit bone resorption, promote urinary excretion
- Bisphosphonates – block osteoclasts. Caution in renal disease.
- Loop diuretics – inc urinary excretion
- Glucocorticoids – useful in granulomatous dz or lymphoma
- Denosumab – inhibits RANKL (osteoclasts)
- Calcimimetics – reduces PTH – used on 2nd hyperparathyroidism in CKD
- Dialysis – low or no Ca dialysate
Adenosine deaminase (ADA) is a test that can be performed on pleural fluid to assess for tuberculosis.
- Values >40 U/L are suggestive of TB. Specificity is increased if the value is greater than 50 U/L and use is combined with lymphocyte/neutrophil ratio.