Intern Case Presentation

Mrs EB
Overview
• Mrs B, 80yo woman, home alone, I with ADLs
• Presents with:
▫ 1/52 vomiting & diarrhoea, fatigue, malaise
▫ 5/7 constipation
▫ 3-4/7 severe generalised abdominal pain
▫ ~20kg weight loss since 4/08!
▫ Nil fevers/sweats; nil haematemesis/melaena/PR bleed
• PHx
▫ Metastatic breast ca  T3, ribs, femur, lungs on exemestane,
monthly zolendronic acid (Zometa)
▫ Sick sinus sx (PPM inserted 4/4/08)
▫ Parathyroid adenoma
▫ Past DVT/PE on warfarin
▫ Rx: tamoxifen, warfarin, perindopril, vitamin D, pantoprazole,
bisoprolol, GTN
Further PMHx
• Breast Ca:
▫ Dx 26 years ago: mastectomy, chemo,
radiotherapy
▫ Recurrence 5 years ago; lung mets discovered and
resected; commenced on aromatase inhibitor
▫ 4/08: bony mets  ribs 8 & 9, T3, femur
 Switched from aromatase inhibitor  tamoxifen
 Commenced on monthly zolendronic acid (bony
mets)
Further PMHx
• Parathyroid adenoma:
▫ Episode of hypercalcaemia 4/08
▫ PTH found to be high ?cause
▫ Sestamibi parathyroid scan: area of avid sestamibi
uptake right lower neck corresponding to
2.0x1.0cm density on SPECT/CT ?parathyroid
adenoma
▫ Surgery refused at this stage
• Sick sinus syndrome:
▫ Permanent pacemaker inserted 4/08
Examination Findings
• General findings
▫ Unwell thin looking elderly lady
▫ JVP low
▫ Dry mucous membranes
▫ BP 110/50, HR 100/regular, SaO2 95% RA, afebrile
• Abdominal exam
▫ Generalised tenderness w/o peritonism
▫ Bowel sounds present
• Chest
▫ Clear lung fields
▫ Dual heart sounds no added sounds
Investigations
• FBE: Hb 143/WCC 9.7/PLT 268
• UEC: Na 129/K 3.3 Urea 13.4 Creat 92 eGFR 54
(baseline >60)
• Ca2+: 3.29; albumin 37; corr ca 3.35; Phos
0.75; Mg2+ 0.61
• CRP 1.4, LFT normal
• AXR: multiple fluid-air levels suggestive of small
bowel ileus.
• CXR: old right lower zone changes
Diagnosis
• Hypercalcaemia causing
secondary ileus and marked
volume depletion

• Dx Dilemma: cause = bony mets,

parathyroid tumour or both?
Initial Management
• Rehydration: 1L N. Saline/2hrs (ED), 4L N.
Saline/24hrs (and continued)
• Not for bisphosphanates as already on monthly
zolendronic acid
• Ileus managed conservatively
Further Ix & Mx
Date 0145 24/6 0731 24/6 1900 24/6 0950 25/6 26/6
Calcium 3.29 2.84 2.92 2.81 2.57

• PTH 6/4/08 = 26.3, Sestamibi- right lower neck PTH

adenoma; sestamibi-avid metastatic disease right ribs,
pleura, hilum ?PTHrP secreting mets
• Endocrinology:
▫ Dx likely due to combination of met breast ca and primary
parathyroidism
▫ Recommended surgical referral for r/o adenoma
• However: PTH now = 0.1 (Suppressed by very high
calcium?)
• Sestamibi scan for diagnosis of parathyroid lump, surgical
opinion to follow
• Therefore diagnosis: Hypercalcaemia secondary to
bony metastatic disease.
Hypercalcaemia
 The presentation
of Hypercalcaemia
can be as vague
and confusing
as this patient!
Calcium, Vit D, PTH metabolism
Calcium, Vit D, PTH metabolism
Calcium, Vit D, PTH metabolism
Causes :: Overview
• Parathyroid Adenomas Account for >90% of cases!
• Malignancy
• Renal failure
• Paget’s Disease
• Drugs – thiazides, calcium, lithium…
• Endocrine: Hyperthyroidism, addisonism
• Genetic – Hypervitaminosis D, Hypercalcaemic
hypocalciuria
• Sarcoidosis, Granulomatosis (incl TB)
Causes :: When to suspect
• Past history of malignancy- esp bony mets, multiple
myeloma
• Endocrine problems
• On calcium supplementation
• Renal patients
• Old people, delirium, confusion of unknown
aetiology
• Specific drugs – calcium, lithium, thiazides, vitamin
D etc
• Other indicators in HOPC/PHx
Causes :: Malignancy 
(Poor prognostic factor)
Investigations
• Serial Ca, PO4
• Correct Ca with albumin!!
▫ (40-Alb)*0.2 + serum Ca = corrected Ca
• UEC – renal function (ARF 2° dehydration/hypercalcaemia,
CRF causing hypercalcaemia)
• PTH level, ALP, Vit D
• Consider multiple myeloma screen – ESR, serum
electrophoresis, urine BJP etc.
• Consider ordering urine calcium – 24 hour urine calcium
collection
• High PTH - Hyperparathyroidism: Sestamibi parathyroid scan
• Low PTH - Malignancy: CT chest, abdo, pelvis, bone scan
Management
• REHYDRATE aggressively with normal saline (aim for
200-300mL/hr initially then urine output 100-
150mL/hr)
▫ Volume depletion most dangerous complication acutely
▫ Na+, H2O administration  renal Ca excretion
• Frusemide if overloaded – promotes renal ca excretion
• IV bisphosphanate eg pamidronate if Ca>3
• Calcitonin if Ca resistant to intervention
• Steroids in granulomatous disease, multiple myeloma,
others
• If Ca still doesn’t come down- consider haemodialysis
And of course…
• Treat the underlying cause.
• Renal failure:
▫ 2° hyperparathyroidism (high PTH)
 Calcimimetics – cinacalcet
 Vit D analogues (not increasing Ca) – paracalcitriol
▫ 3° hyperparathyroidism (autonomic PTH)
 Surgical intervention
• Parathyroid nodule/tumour: surgical intervention
• Granulomatous disease: steroids
• Drugs: cease offending drug
• Treat endocrine conditions