Endocrine Abstracts

Background: Hypercalcaemia is a commonly encountered electrolyte abnormality within the acute medical take; identification of the underlying aetiology can guide optimised care.

Case : A 23 year old male patient with a background of insulin dependent diabetes, diabetic nephropathy (chronic kidney disease stage 1) was admitted feeling acutely unwell. Clinical and bed side investigations identified he was in severe diabetes ketoacidosis. His condition prompted a prolonged hospital stay of at least six months which included three months of Intensive care unit admission. It was identified that his DKA was triggered by sepsis from dental infection which was complicated by multiple brain infarcts and disseminated intravascular coagulation. He was appropriately treated with intravenous antibiotics and fixed rate insulin infusion. In his fourth month into admission, he was noted to have raised calcium levels, values ranging from 2.8 – 3.4mmol/l, moderately raised phosphate with a low Parathyroid hormone level of 0.7 to 1.0. His vitamin D levels were normal. Urinary calcium levels were within normal ranges. CT abdomen and chest were unremarkable with no signs of malignancy. He was treated with phosphate binders (sevelamer), started on slow IV fluids. His long-term cholecalciferol was withheld. Patient also received intermittent dialysis for prerenal acute kidney injury. Despite all these interventions, he persistently had high calcium levels which was later attributed to patient’s long stay in hospital whilst immobile.

Conclusion: It is vital to fully investigate for all the causes of hypercalcaemia before concluding hypercalcaemia of immobilisation. This was a complicated case in which one expects patient to develop hypocalcaemia from chronic kidney disease. Hypercalcaemia from immobilisation is uncommon but we have to think about it in patients who have long periods of hospital stay.