Endocrine Abstracts

Authors: Mohamed Coco, Katrina Sheikh, Basheir Osman, Jayadave Shakher: Department of Acute Internal Medicine, Birmingham Heartlands Hospital-University Hospitals Birmingham

Introduction: Although skeletal metastatic diseases have commonly been associated with hypercalcemia; we present a case of severe hypercalcemia secondary to extensive skeletal sclerotic metastatic disease.

Case: A 92 year-old female was admitted from nursing home following a fall\.. She is known to have Alzheimer’s disease, Type 2 diabetes and chronic kidney disease.

Lab results: Corrected Calcium: 1.6 mmol/l with normal C. Ca, 1 year ago (normal range 2.20 to 2.60). ALP >4555 IU/L(30-130), PO4: 1.29 mmol/l (0.8-1.5), Hb: 87 g/l (115-145), MCV 101 fL(81-102), eGFR 57 (baseline), Bilirubin, INR and liver enzymes were normal. Further tests shewed Vitamin D of 65.1 nmol/l (>49.9) and PTH of 41.5 pmol/l (2.7-11.1) Her severe cognitive impairment meant symptoms of hypocalcaemia were not elicitable.

Management: She was started on IV Calcium gluconate with oral alfacalcidol. Her Corrected Ca continued to be low despite of repeated Calcium infusions and alfacalcidol. Given the above abnormal blood tests (unexplained severe Hypocalcaemia with a very high ALP) a CT Thorax, Abdomen and Pelvis with contrast was done which showed evidence of extensive skeletal sclerotic metastatic disease with unclear primary although some suspicious areas were evident in left breast.

Discussion: Hypocalcaemia is uncommon in the context of malignancy. It is believed that osteoblastic bone metastasis can lead to increase influx of calcium and phosphate into the bone leading to hypocalcaemia. Common cancers associated with this are Breast and Prostate cancers.

Treatment: The treatment of Hypocalcaemia secondary to osteoblastic metastatic disease includes high dose of calcium and vitamin D-especially the active form Calcitriol-Treatment of underlying cancer may help. Rarely, patients may require prolonged calcium infusion.