Interesting case of severe life threatening hypercalcaemia that is non-PTH mediated, so the pathophysiology could be:
1. Malignancy; Humoral and lytic bone lesions were excluded, however ectopic calcitriol production by lymphoma is a consideration.
2. Granulomatous disorders: TB & sarcoidosis ruled out.
3. Vitamin D or vitamin A intoxication.
4. Occult milk alkali syndrome.
5. Drug induced, Lithium and thiazide diuretic can only cause mild hypercalcaemia, however if the acute renal failure was precipitated by olanzapine induced rhabdomyolysis then this could accentuate lithium associated hypercalcaemia.
6. Thyrotoxicosis and Addison's disease can also be associated with mild hypercalcaemia mainly.
Conclusion: Most likely lithium associated hypercalcaemia accentuated by acute renal failure, but malignancy such as lymphoma and occult milk alkali syndrome are equally likely.
Regards
Mohammad
Dr. M A Al-Jubouri, MB ChB, MSc, EurClinChem, FRCP Edin, FRCPath
Consultant Chemical Pathologist
--------------------------------------------
On Thu, 2/13/14, JONES Stuart (Pathology) (RF4) BHR Hospitals <[log in to unmask]> wrote:
Subject: Mystery hypercalcaemia
To: [log in to unmask]
Date: Thursday, February 13, 2014, 5:14 PM
A unusual case of
hypercalcaemia for you to ponder:
75yo man presented to
AE severe symptomic hypercalcaemia and acute kidney
injury: Ca 4.11.
Background
Known previous TB
+ Thoracoplasty 1958
Gallstones removed via
ERCP 2012
Bipolar affective disorder
and depression >40yrs. On lithium therapy (600mg OD 2013)
since at least 2005 with serum levels stable.
Long standing normocytic
anaemia (stable Hb at ~125)
Other
meds:
Olanzapine
Mirtazapine
Zopiclone
Other admission
bloods:
CR 502, UR 31, Na/K
normal
aCa 4.11, PO4 1.90, ALP
134
PTH <0.3, Vit D 22, ACE
36.2 (15-70)
FBC - Hb 111, WBC 11.1,
MCV 92.7
LFT - NAD
Electrophoresis/BJP - NAD
but raised beta 2 microglobulin (?secondary to
RF)
Lithium 0.63.
PTHrP -
Undetectable
Other
investigations
XR/CT chest -
abnormalities but confirmed by Resp team opinion
was changes were earlier secondary to TB/thoracplasty
and not any recent changes.
No evidence of active TB
or sarcoid
Skeletal survey and
all other MRI/CT - NAD
Patient denies any OTC
meds or remedies
Treatment
Rehydrated, lithium
stopped - Ca down to 2.65 two weeks
later
Calcium then inexplicably
rises again to 3.6
He's given 30mg
pamidronate (2 doses) and a few days later cinacalcet
(single dose) which causes calcium to drop to 2.05 over
the course of 1 week.
His vit D is then
normalised with 50,000U bolus of cholecalciferol
and his calcium stablises at around 2.40 with CR 110.
Patient discharged 3 days later.
Questions
Is it possible the lithium
is responsible depsite non-toxic levels and long standing
treatment without incident?
What are we
missing???
Stuart
Stuart Jones
|
Principal
clinical biochemist
Clinical biochemistry / Pre-natal
screening
King George Hospital
Barking, Havering and Redbridge University
Hospitals NHS Trust
Technical lead | Lab Tests Online UK
http://www.labtestsonline.org.uk/
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