Endocrine Abstracts

Hypercalcaemia is a commonly encountered problem. Though primary hyperparathyroidism and malignancy account for greater than 90% of cases other rare causes need to be considered. We present an unusual but significant cause of hypercalcaemia.

Of 87-year-old gentleman presented with acute abdominal pain and a severe hypercalcaemia with corrected serum calcium of 4.36 mmol/l (2.1–2.6). Significant dehydration was associated with acute renal failure (Table 1). In spite of this there was metabolic alkalosis at presentation. Delirium and confusion complicated the clinical course though haemodynamically stable. Parathyroid levels were appropriate. All other investigations including myeloma and malignancy screen including imaging studies were negative. No evidence for pancreatitis. Detailed history from family revealed intake of antacids though not in large quantities leading to a diagnosis of milk-alkali syndrome. With prompt rehydration and parenteral bisphosphonates the calcium levels normalised and renal failure improved. He was advised not to take over the counter medications like calcium carbonate and antacids without consultation. At subsequent follow up corrected calcium levels remain normal.

There is a resurgence of milk -alkali syndrome and now it is considered to be the third common cause of hypercalcaemia next only to primary hyperparathyroidism and malignancy. More than 50% present with an acute form characterised by psychosis, metabolic alkalosis, acute renal impairment and normal to elevated serum phosphate levels. Discontinuation of milk and alkali will promptly improve the condition. In modern times calcium carbonate is found to be the commonest source.

In conclusion, careful history taking might help to make a diagnosis and aid the management in conditions like milk-alkali syndrome.