Hypercalcemia

Hypercalcemia can be caused by conditions such as hyperparathyroidism, malignancy, granulomatous diseases (TB, sarcoidosis), milk alkali syndrome, total parenteral nutrition, adrenal insufficiency, pheochromocytoma and by drugs (thiazides, vitaminA, anti estrogens).

Celiac disease is not associated with hypercalcemia.

Ref: Harrison’s Internal Medicine, 18th Edition, Chapter 46; Textbook of Clinical Pediatrics By A. Y. Elzouk, Volume 1, Pages 1895-9

All the features mentioned above in the question are features of hypercalcemia except  diarrhea. Hypercalcemia causes constipation, not diarrhea. So diarrhea is the single best answer of choice.

Ref: Harrisons Principles of Internal Medicine, 16th Edition, Page 2252.

This is a question repeated often. Tumor lysis syndrome causes hypocalcemia. 

A normal serum calcium level is 8-10 mg/dL (2-2.5 mmol/L) with some interlaboratory variation in the reference range, and hypercalcemia is defined as a serum calcium level greater than 10.5 mg/dL (>2.5 mmol/L).

Ans. is d i.e., Hyperparathyroidism

o Chronic thiazide therapy causes hypercalcemia because it enhances the parathyroid mediated increase of Ca reabsorption.

Answer is B (Decreased QT interval)

Hypercalcemia is characterized by a decreased QT interval.

Answer is B (Primary Hyperparathyroidism) :

The most likely cause of asymptomatic hypercalcemia in a patient aged 30 _.years is primary hyperparathyroidism. Familial hypocalciuric hypercalcemia, is most often detected in the first ten years of life when hypercalcemia due to primary hyperparathyroidism is a rarity.

Both primary hyperthyroidism and familial hypocalciuric hypercalcemia may present with asymptomatic hypercalcemia.

The ‘catch’ in the above question lies in the ‘are’ of the patient

Answer is C (Urinary Calcium levels):

Estimation of urinary calcium excretion is the most important test to distinguish Familial Benign Hypercalcemia from Primary Hyperparathyroidism.

Familial Hypocalciuric Hypercalcemia (also called familial Benign Hypercalcemia) overlaps mild cases of Primary Hyperparathyroidism biochemically, hormonally and clinically. PTH Concentrations do not distinguish the two disorders. Familial Hypocalciuric Hypercalcemia (also called Familial Benign Hypercalcemia) is typically associated with decreased excretion of calcium in urine while calcium excretion in urine is increased in Primary Hyperparathyroidism. Increased excretion of calcium can be estimated by 24-hour urinary calcium excretion or by the calcium creatinine clearance ratio both of which are typically decreased in Familial Benign Hypercalcemia

Answer is D (Vitamin A deficiency).

Hypercalcemia is seen with Vit. A intoxication (not deficiency) due to associated high bone turnover. Causes of hypercalcemia:

Answer is D (Celiac disease):

Celiac disease is not a cause for hypercalcemia.

Hyperparatlzyroidism, Sarcoidosis and Milk alkali syndrome, may all lead to hypercalcemia.

Answer is D (Phenytoin toxicity):

Repeat Phenytoin toxicity is associated with hypocalcemia.

Answer is D (Acute pancreatitis):

Acute Pancreatitis is a miscellaneous cause for Hypocalcemia (not hypercalcemia).

Note that Hypercalcemia may cause Acute Pancreatitis but Acute Pancreatitis causes hypocalcemia Q.

Multiple myeloma, Lytic skeletal metastasis and excessive calcium intake from Total Parentral Nutrition are all established causes of Hypercalcemia

Causes of Hypercalcemia:

CaSR, calcium sensor receptor; FHH, familial hypocalciuric hypercalcemia; PTH, parathyroid hormone; PTHrP, PTH-related peptide.

Answer is D (Furosemide):

Thiazide diuretics cause hypercalcemia while loop diuretics (furosemide) cause hypocalcemia.

Furosemide is a loop diuretic that is characteristically associated with hypocalcemia and not hypercalcemia.

Answer is D (Rizol)

Principles

• The first principle of treatment is to restore normal hydration ^Q as most hypercalcemia patients are dehydrated because of vomiting and polyuria etc.
• After rehydration has been achieved, saline can be administered
• Loop diuretics such as furosemide & ethacrynic acid can then be administered to depress tubular calcium resorption and enhance calcium excretion. Thiazide diuretics are not to be used.
• Glucocorticoids have antitumor effect and are especially useful in hypercalcemia complicating malignancies.
• Dialysis:is the treatment of choice for severe hypercalcemia complicating renal failure.
• Phosphate therapy – Correcting hypophosphatemia lower serum calcium sometimes strikingly.

Answer is A (Normal saline with forced diuresis with Thiazides):

Thiazide diuretics should not be used in cases of hypercalcemia as these may themselves cause hypercalcemia.

Answer is A and B (Calcitonin and Gallium Nitrate):

Calcitonin and Gallium Nitrate may be used in treatment of hypercalcemia.

Answer is D (Pamidronate is not effective):

Pamidronate is a second generation hiphosphonate that is approved for intravenous use in the treatment of hypercalcemia.

Answer is C (Vitamin Din high doses):

Vitamin D administration is associated with hypercalcemia and hence it cannot be used in the treatment of hypercalcemia

Answer is D (Gallium Nitrate)

Gallium Nitrate exerts s hypocalcemic effect by inhibiting calcium resorption from bone. Maximum hypocakemic

effect of gallium nitrate may take 3-4 days to appear and it is not often used now because of availability of superior alternatives.

Gallium nitrate is the single best answer of exclusion.

Answer is D (Bisphosphonates):

Bisphosphonates have a delayed onset of action beginning after days and are not recommended in patients with renal failure. Bisphosphonates is the single best answer by exclusion.

Ans. C i.e. Pseudohypoparathyroidism

Pseudohypoparathyroidism presents with hypocalcemia, normal to raised PTH, normal 25-(OH)D, and decreased 1,25-(OH),D

Ans. C i.e. Lithium