Endocrine Abstracts

Background: Hypercalcemia is a common clinical problem. Severe hypercalcemia or hypercalcemic crisis is an endocrine emergency and can be life threatening if left untreated. The condition has high mortality and requires immediate therapeutic interventions and diagnostics. A rapid rise to the calcium levels can result in the impaired function of organ systems including central nervous system. Hypercalcemia is mainly (more than 90%) caused by primary hyperparathyroidism or malignant conditions.

Clinical case: A 63-year-old man with background history of alcohol abuse presented to our institution with acute confusional state. Collateral history revealed that he was wandering in the streets. He was found pleasantly confused and disorientated by local police who brought him to the hospital. His physical examination revealed a Glasgow coma scale (GCS) score of 13/15 with no obvious localizing signs or neurological deficit. Initial investigations showed alcohol levels of less than 10 mg/dl, negative toxicology screen, unremarkable CT brain with normal blood glucose and serum amylase levels. He had decreased urinary output of 15-20 ml/hr with normal renal function but raised calcium levels of 3.72 mmol/l (2.20-2.60) and low phosphate levels of 0.77 mmol/l (0.8-1.5).He was treated as hypercalcemic crisis with intravenous fluids and given intravenous bisphosphonate (zolendronic acid 4 mg) in critical care unit. His calcium levels started decreasing with the treatment and his conscious level significantly improved. The diagnostics included low PTH levels with value of 6.7 pg/ml (15-65) and CT of thorax, abdomen and pelvis which revealed a left renal lesion of 15 x 12 cm² infiltrating into anterior and posterior perinephric soft tissue.He was referred to urology department for further investigations. Histopathology of renal biopsy specimen showed renal cell carcinoma and graded as advanced renal cancer (Stage IIIc). Unfortunately, due to his baseline status and compliance issues he was not deemed a candidate for surgery or systemic therapy and advised consideration for palliative approach.

Conclusion: The case illustrates the need to carefully review the differentials of hypercalcemia and consider immediate treatment interventions in situations of severe hypercalcemia or hypercalcemic crisis. Renal cell carcinoma should be considered as possible causative in hypercalcemia of unknown underlying pathology.Key words: hypercalcemia, hyperparathyroidism, cancer