Calcium Dysregulation

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Ddx

Adrenal insufficiency/thryotoxicosis

TSH- low

free T4- inc

lid retraction/lag

muscle weakness

moist skin

goiter

tremor

tachycardia

weight loss with increased appetite?

Subtopic

Fatigue or weakness?

palpitations?

heat intolerance?

increased irritability?

Acute Renal Failure

electrolytes- abnormal

shortness of breath

nausea

edema

recent hospitalization?

recent fatigue?

recent change in urine output?

Drugs

25-hydroxyvitamin D- inc

1,25-dihydroxyvitaminD- not elevated

PTHrP- not elevated

PE findings

abdominal pain

bone pain

N/V

Taking any other medications in addition to Metropolol?

Li, Antacids, Thiazide diuretic, Vit D. intoxication

Granulomatous Disease

Sarcoidosis, TB

PTHrP- now elevated

PTH- low

1,25-dihydroxyvitaminD- inc

infiltrative lesion

Increased thirst?

Hx of TB

Multiple Endocrine Neoplasm

Labs

Prolactin

Gastrin, insulin, glucagon, somatostatin levels

all possibly increases

Genetic testing

mutation in Menin gene

weakness

bone abnormalities, pain

weight loss

glucagonoma

pain with abdominal palpation

gastrinoma

FHx of MEN?

Hypercalcemia of malignancy- Metastatic tumor

X-ray

SCC lung metastatic tumor

CBC w diff

leukemia, multiple myeloma

CT/MRI

pancreas metastatic tumor

Mammogram

Breast metastatic tumor

PTHrP assay

inc PTHrP, dec iPTH

Ultrasound

thyroid metastatic tumor

Non-tender, firm, immobile mass

PMHx or FHx of cancer?

Secondary Hyperparathyroidism

Labs for CKD/malabsorption

1,25 dihydroxy vit D

dec

25 (OH) vit D

dec in surgical malabsorption

normal

alk phophs

inc +/-

blood work

anemia

serum PO4

serum Ca

hypocalcemia

PE

Abdominal pain from nephrolithiosis

Bone/joint pain

Recent kidney issues, such as kidney stones?

New aches for pains?

Primary Hyperparathyroidism

Additional labs

EKG

heart block, bradyarrythmia

tall, peaked T waves, short QT interval

Cr/BUN, 24hr urine for Ca and Cr

rule out other etiologies

25 (OH) vitamin D

low +/-

Serum PO4

decreased

Urinary Calcium and PO4

increased

iPTH

increase

Pre-op sestamibi-iodine subtraction scanning and ultrasound of neck

X-ray/DEXA

PUD

may show show dec bone density, brown tumor

usual normal

PTH

High

Chronic duration- Parathyroidism

Acute duration- Primary hyperparathyroid

Repeat Calcium

Hypercalcemia

Usual PE findings

Palpitations

Abdominal pain

Decreased DTR

Myalgia

Proximal weakness

Mild bone pain

Questions

Change in energy levels?

Change in mood?

N/V?

Previous DEXA scan?

Last menstrual period?

Treatment

General treatment and eduction

long term monitoring: serum calcium, iPTH, DEXA

Avoid thiazides, large doses of Vit D, calcium, or immboilization

increase water intake and exercise

Surgical exploration with partial parathyroidectomy

Complications

chronic hypocalcemia requiring life-long calcium and vitamin D supplemention

hypoparathyroidism

injury to recurrent laryngeal nerve(s)

Calcium Dysregulation