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/
 
 
 Barking, Havering & Redbridge University Hospitals NHS
 Trust: Working to make our hospitals better.
 
 This communication, together with any files or attachments
 transmitted with
 it contains information which is confidential and may be
 subject to legal 
 privilege and is intended solely for the use by the
 person(s) or entity to 
 whom it is addressed. If you are not the intended recipient
 you must not 
 copy, distribute, publish or take any action in reliance on
 it. If you have 
 received this communication in error, please notify 
 [log in to unmask] and delete it from your
 computer systems.
 
 Barking, Havering & Redbridge University Hospitals NHS Trust
 reserves the 
 right to monitor all communications for lawful purposes.
 Receipt of this email 
 does not imply consent to use or provide this email address,
 or any others 
 contained therein, to any third party for any purposes. The
 contents of this
 email are protected under international copyright law.
 
 To save energy and paper please print this email only if you
 really need to. 
 _____________________________________________________________________________
 
 This email has been scanned for viruses using antivirus
 software by 
 Barking, Havering & Redbridge University Hospitals NHS
 Trust. Whilst every
 care is taken to avoid the transmission of virus code;
 please ensure that you 
 have up to date virus detection software before opening any
 E-mail 
 messages or attachments 
 ______________________________________________________________________________
 
 
 
 ------ACB discussion List Information--------
 This is an open discussion list for the academic and
 clinical community working in clinical biochemistry.
 Please note, archived messages are public and can be viewed
 via the internet. Views expressed are those of the
 individual and they are responsible for all message content.
 ACB Web Site
 http://www.acb.org.uk
 Green Laboratories Work
 http://www.laboratorymedicine.nhs.uk
 List Archives
 http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
 List Instructions (How to leave etc.)
 http://www.jiscmail.ac.uk/
 

------ACB discussion List Information--------
This is an open discussion list for the academic and clinical community working in clinical biochemistry.
Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content.
ACB Web Site
http://www.acb.org.uk
Green Laboratories Work
http://www.laboratorymedicine.nhs.uk
List Archives
http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
List Instructions (How to leave etc.)
http://www.jiscmail.ac.uk/