Review Question - QID 104352

In a patient with asymptomatic hypercalcemia the first test should be to confirm hypercalcemia with a second serum calcium. If this test returns positive, then a PTH level is the next step in management. If the hypercalcemia were severe or there were symptoms in this patient the management would be: 1. IV fluids, 2. Loop diuretics (furosemide) 3. Calcitonin then 4. Bisphosphonates (long term management). Often times only IV fluids and a loop diuretic are needed.

The clinical features of hypercalcemia include the classic stones (kidney stones), bones (aches and pains), groans (constipation), and psychiatric overtones (depression and mood liability). However, this patient presents without these clinical features, and thus a reasonable next step would be to confirm the hypercalcemia. Recall the various causes of hypercalcemia. The broad differential includes endocrinopathies, malignancies, and pharmacologic causes. Endocrinopathies include hyperparathyroidism. Malignancies include any metastatic cancers to the bone, multiple myeloma, and PTH-like peptide producing cancers such as squamous cell lung cancer. Pharmacologic causes include Vitamin D, milk-alkali syndrome, and certain medications such as thiazides, and lithium. Other less common causes are sarcoidosis and familial hypocalciuric hypercalcemia.

Carroll and Schade review hypercalcemia. The diagnosis is often made incidentally in asymptomatic patients. The most common causes in clinical practice are primary hyperparathyroidism and malignancy. Aggressive IV hydration is the key step in management of severe hypercalcemia with calcitonin, bisphosphonates, and loop diuretics significant adjuncts.

Silverberg et al. discuss asymptomatic primary hyperparathyroidism. Although it was initially expected that patients with asymptomatic hyperparathyroidism would eventually develop clinical symptoms, observational data suggest that most of these patients tend not to become symptomatic.

Illustration A depicts the usual location of the four parathyroid glands within the thyroid. Illustration B shows an algorithm for managing hypercalcemia.

Incorrect Answers:
Answer 1: Ordering a parathyroid level would be reasonable in a patient who presents with hypercalcemia and the cardinal clinical features.
Answers 2 and 5: These choices are reasonable in the workup where hypercalcemia of malignancy is expected.
Answer 4: An ACE would be a reasonable step in a patient with hypercalcemia and some features of sarcoidosis. Since the ACE is a very sensitive but not highly specific test for sarcoidosis, other workup would also be indicated including chest radiograph.