Tag: Hypercalcemia

Hypercalcemia

Hypercalcemia

Q. 1

Hypercalcemia is associated with all of the following, except:

 A

Sarcoidosis

 B

Celiac disease

 C

Milk alkali syndrome

 D

Hyperparathyroidism

Q. 1

Hypercalcemia is associated with all of the following, except:

 A

Sarcoidosis

 B

Celiac disease

 C

Milk alkali syndrome

 D

Hyperparathyroidism

Ans. B

Explanation:

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


Q. 2

Which of the following is not a feature of hypercalcemia:

 A

Diarrhea

 B

Polyuria

 C

Depression

 D

Vomiting

Q. 2

Which of the following is not a feature of hypercalcemia:

 A

Diarrhea

 B

Polyuria

 C

Depression

 D

Vomiting

Ans. A

Explanation:

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.


Q. 3

Which of the following is not associated with hypercalcemia?

 A

Tumor lysis syndrome

 B

Hyperparathyroidsm

 C

Multiple sclerosis

 D

Sarcoidosis

Q. 3

Which of the following is not associated with hypercalcemia?

 A

Tumor lysis syndrome

 B

Hyperparathyroidsm

 C

Multiple sclerosis

 D

Sarcoidosis

Ans. A

Explanation:

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).

Quiz In Between


Q. 4

Chronic thiazide therapy causes persistent hypercalcemia due to –

 A

Renal tubular acidosis

 B

Fanconi’s syndrome

 C

Hypervitaminosis D

 D

Hyperparathyroidism

Q. 4

Chronic thiazide therapy causes persistent hypercalcemia due to –

 A

Renal tubular acidosis

 B

Fanconi’s syndrome

 C

Hypervitaminosis D

 D

Hyperparathyroidism

Ans. D

Explanation:

Ans. is d i.e., Hyperparathyroidism

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


Q. 5

Hypercalcemia in ECG is diagnosed by:

 A

Increased QT interval

 B

Decreased QT interval

 C

Increased PR interval

 D

Tall T waves

Q. 5

Hypercalcemia in ECG is diagnosed by:

 A

Increased QT interval

 B

Decreased QT interval

 C

Increased PR interval

 D

Tall T waves

Ans. B

Explanation:

Answer is B (Decreased QT interval)

Hypercalcemia is characterized by a decreased QT interval.


Q. 6

Asymptomatic hypercalcemia in a 30 year old young male is due to :

 A

Occult primary malignancy

 B

Primary Hyperparathyroidism

 C

Familial hypocalciuria

 D

Hyper-nephroma

Q. 6

Asymptomatic hypercalcemia in a 30 year old young male is due to :

 A

Occult primary malignancy

 B

Primary Hyperparathyroidism

 C

Familial hypocalciuria

 D

Hyper-nephroma

Ans. B

Explanation:

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

 

Primary hyperparathyroidism              

Familial hypocalciuric hypercalcemia (F.H.H.) (autosomal dominant)

 

The most common presentation in patients with primary hyperparathyroidism is `asymptomatic’ hypercalcemia

Commonly presents in third to fifth decade

Affected individuals are discovered because of asymptomatic hypercalcemia

Commonly presents in the first decade

 

Quiz In Between


Q. 7

Which of the following tests is used to distinguish Primary Hyperparathyroidsm from Familial Benign Hypercalcemia:

 A

Serum PTH Levels

 B

Srum Calcium levels

 C

Urinary Calcium levels

 D

Serum Phosphorus levels

Q. 7

Which of the following tests is used to distinguish Primary Hyperparathyroidsm from Familial Benign Hypercalcemia:

 A

Serum PTH Levels

 B

Srum Calcium levels

 C

Urinary Calcium levels

 D

Serum Phosphorus levels

Ans. C

Explanation:

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


Q. 8

Hypercalcemia is not seen in:

 A

Lithium therapy

 B

Chronic renal failure

 C

Multiple myeloma

 D

Vitamin A deficiency

Q. 8

Hypercalcemia is not seen in:

 A

Lithium therapy

 B

Chronic renal failure

 C

Multiple myeloma

 D

Vitamin A deficiency

Ans. D

Explanation:

Answer is D (Vitamin A deficiency).

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

 

Parathyroid related                              

 

Vitamin D related                                        

Primary hyperparathyroidism Q

Lithium therapy Q

Familial hypercalciuric hypercalcemia

Vitamin D intoxication

Increased 1, 25 (OH), D eg. SarcoidosisQ; other granulomatous ds.

Idiopathic hypercalcemia of infancy

 

Malignancy related

 

Associated high bone turnover                        

Solid tumor with metastasis (Breast)

HyperthyroidismQ

Solid tumor with paraneoplastic syndromes

hnmobilizationu

 

(Carcinoma Breast/Lung /Kidney etc.)

ThiazidesQ

Hematological malignancies:

Vitamin A intoxicationQ

 

Multiple myelomaQ / Lymphoma /

Paget ‘s disease

 

Leukemia

 

Associated With Renal FailureQ                                           

Pheochoromocytoma (rare)

Severe secondary hyper-parathyroidism

MEN syndromes

Aluminum intoxication

 

 

Milk Alkali syndrome


Q. 9

Hypercalcemia is associated with all Except:

 A

Hyperparathyroidism

 B

Sarcoidosis

 C

Milk alkali syndrome

 D

Celiac disease

Q. 9

Hypercalcemia is associated with all Except:

 A

Hyperparathyroidism

 B

Sarcoidosis

 C

Milk alkali syndrome

 D

Celiac disease

Ans. D

Explanation:

Answer is D (Celiac disease):

Celiac disease is not a cause for hypercalcemia.

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

Quiz In Between


Q. 10

All are causes of hypercalcemia, except:

 A

Thyrotoxicosis

 B

Sarcoidosis

 C

Vitamin A toxicity

 D

Phenytoin toxicity

Q. 10

All are causes of hypercalcemia, except:

 A

Thyrotoxicosis

 B

Sarcoidosis

 C

Vitamin A toxicity

 D

Phenytoin toxicity

Ans. D

Explanation:

Answer is D (Phenytoin toxicity):

Repeat Phenytoin toxicity is associated with hypocalcemia.


Q. 11

Causes of Hypercalcemia include all of the following except

 A

Multiple myeloma

 B

Lytic skeletal metastasis

 C

Total parentral nutrition

 D

Acute Pancreatitis

Q. 11

Causes of Hypercalcemia include all of the following except

 A

Multiple myeloma

 B

Lytic skeletal metastasis

 C

Total parentral nutrition

 D

Acute Pancreatitis

Ans. D

Explanation:

 

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:

Excessive PTH •roduction

•  Primary hyperparathyroidism (adenoma, hyperplasia, rarely carcinoma)

•  Tertiary hyperparathyroidism (long-term stimulation of PTH secretion in renal insufficiency)

•  Ectopic PTH secretion (very rare)

•  Inactivating mutations in the CaSR (FHH)

•  Alterations in CaSR function (lithium therapy)

Hypercalcemia of malignancy

•  Overproduction of PTHrP (many solid tumors)

•  Lytic skeletal metastases (breast, myeloma)

Excessive 1,25(OH)2D production

•  Granulomatous diseases (sarcoidosis, tuberculosis, silicosis)

•  Lymphomas

•  Vitamin D intoxication

Primary increase in bone resorption

•  Hyperthyroidism

•  Immobilization

Excessive calcium intake

•  Milk-alkali syndrome

•  Total parenteral nutrition

Other causes

•  Endocrine disorders (adrenal insufficiency, pheochromocytoma, VIPoma)

•  Medications (thiazides, vitamin A, antiestrogens)




















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

 

 


Q. 12

Hypercalcemia is caused by all except:

 A

Thyrotoxicosis

 B

Vit. D intoxication

 C

Sarcoidosis

 D

Furosemide

Q. 12

Hypercalcemia is caused by all except:

 A

Thyrotoxicosis

 B

Vit. D intoxication

 C

Sarcoidosis

 D

Furosemide

Ans. D

Explanation:

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.

Quiz In Between


Q. 13

Treatment of hypercalcemia includes, all, except:

 A

Gallium nitrate

 B

Plicamycin

 C

Etidronate

 D

Rizol

Q. 13

Treatment of hypercalcemia includes, all, except:

 A

Gallium nitrate

 B

Plicamycin

 C

Etidronate

 D

Rizol

Ans. D

Explanation:

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.

Q. 14

All of the following may be used to treat hypercalcemia, except:

 A

Normal saline with forced diuresis with chlorthiazide

 B

Plicamycin

 C

Gallium nitrate

 D

Mitramycin

Q. 14

All of the following may be used to treat hypercalcemia, except:

 A

Normal saline with forced diuresis with chlorthiazide

 B

Plicamycin

 C

Gallium nitrate

 D

Mitramycin

Ans. A

Explanation:

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.


Q. 15

Treatment of Hypercalcemia

 A

Calcitonin

 B

Gallium nitrate

 C

Orthophosphate

 D

a and b

Q. 15

Treatment of Hypercalcemia

 A

Calcitonin

 B

Gallium nitrate

 C

Orthophosphate

 D

a and b

Ans. D

Explanation:

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

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

Quiz In Between


Q. 16

All of the following are true about Hypercalcemia, except:

 A

Management of primary cause

 B

Management of primary cause

 C

IV fluid with furosemide is given

 D

Pamidronate is not effective

Q. 16

All of the following are true about Hypercalcemia, except:

 A

Management of primary cause

 B

Management of primary cause

 C

IV fluid with furosemide is given

 D

Pamidronate is not effective

Ans. D

Explanation:

Answer is D (Pamidronate is not effective):

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


Q. 17

All are used in treatment of hypercalcemia, except:

 A

Phosphate

 B

Mithramycin

 C

Vitamin D in high dose

 D

Any of the above

Q. 17

All are used in treatment of hypercalcemia, except:

 A

Phosphate

 B

Mithramycin

 C

Vitamin D in high dose

 D

Any of the above

Ans. C

Explanation:

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


Q. 18

All of the following may be used to treat Acute Hypercalcemia Except:

 A

Hydration with saline

 B

Calcitonin

 C

Biphosphonates

 D

Gallium Nitrate

Q. 18

All of the following may be used to treat Acute Hypercalcemia Except:

 A

Hydration with saline

 B

Calcitonin

 C

Biphosphonates

 D

Gallium Nitrate

Ans. D

Explanation:

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.

Treatment of Hypercalcemia

Onset of Action

Hydration with Saline

Hours

Forced diuresis (saline + loop diuretic)

Hours

Calcitonin

Hours

Intravenous phosphate

Hours

Pheomycin / Mithromycin

Hours

Dialysis

Hours

Biphosphonates

Days (1 to 2 days)

Glucocorticoids

Days

Gallium Nitrate

Days (3-4 days)

Quiz In Between


Q. 19

A 75 year old lady with fracture neck of femur presents with two days history of altered sensorium and decreased urinary output. Serum calcium is 15.5 mg dl, Urea is 140 mg/dl, Creatinine is 2 mg/d1. All of the following are useful for immediate management of Hypercalcemia, Except:

 A

Normal saline

 B

Furosemide

 C

Dialysis

 D

Bisphosphonates

Q. 19

A 75 year old lady with fracture neck of femur presents with two days history of altered sensorium and decreased urinary output. Serum calcium is 15.5 mg dl, Urea is 140 mg/dl, Creatinine is 2 mg/d1. All of the following are useful for immediate management of Hypercalcemia, Except:

 A

Normal saline

 B

Furosemide

 C

Dialysis

 D

Bisphosphonates

Ans. D

Explanation:

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.


Q. 20

Hypercalcemia is seen in all EXCEPT:

 A

Bone metastasis

 B

Sarcoidosis

 C

Pseudohypoparathyroidism

 D

Hyperparathyroidism

Q. 20

Hypercalcemia is seen in all EXCEPT:

 A

Bone metastasis

 B

Sarcoidosis

 C

Pseudohypoparathyroidism

 D

Hyperparathyroidism

Ans. C

Explanation:

Ans. C i.e. Pseudohypoparathyroidism

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

 


Q. 21

Hypercalcemia is decreased by all of the following EXCEPT:        

March 2003, 2007

 A

Etidronate

 B

Calcitonin

 C

Lithium

 D

Glucocorticoids

Q. 21

Hypercalcemia is decreased by all of the following EXCEPT:        

March 2003, 2007

 A

Etidronate

 B

Calcitonin

 C

Lithium

 D

Glucocorticoids

Ans. C

Explanation:

Ans. C i.e. Lithium

Quiz In Between



Hypercalcemia

Hypercalcemia


HYPERCALCEMIA

  • Hypercalcemia is when total serum calcium value is above the upper limit of the normal range or an elevated ionized calcium value.

 Etiology-

I) With normal or elevated PTH levels-

  1. Primary or tertiary hyperparathyroidism (most common)
  2. Li- induced hyperparathyroidism
  3. Familial hypocalciuric hypercalcemia

II) With low PTH levels-

  1. Malignancy (most common)
  2. Elevated 1, 25 (OH)2 vitamin D
  3. Thyrotoxicosis, sarcoidosis, bone metastasis, multiple myeloma
  4. Paget’s disease with immobilisation
  5. Milk- alkali syndrome
  6. Thiazide diuretics
  7. Glucocorticoids deficiency

Clinical features-

  • General- anorexia, fatigue, nausea, pancreatitis
  • Renal- polyuria, polydipsia, renal stones
  • GIT- dyspepsia, peptic ulcer, constipation
  • CNS- impaired cognition, hypertension
  • Metabolic- metastaticcalcification, bone pain, fracture, nephrocalcinosis

 Investigations-

  • Most common investigation is serum PTH level.
  • PTH increased- primary hyperparathyroidism
  • High plasma phosphate & alkali phosphatise- tertiary hyperparathyroidism
  • Low urine calcium excretion- FHH
  • Tests used to distinguish Primary Hyperparathyroidsm from Familial Benign Hypercalcemia- urinary calcium levels
  • Hypercalcemia in ECG is diagnosed by decreased QT interval.

Treatment-

  • Volume expansion- 4-6 lt. Intravenous saline
  • Hypercalcemia of malignancy – Zoledronic acid, pamidronate
  • 1, 25 (OH)2 D mediated hypercalcemia- glucocorticoids
  • Calcitonin- for life threatening hypercalcemia
  • Bisphosphonates- decreased serum calcium

Exam Important

 Etiology-

I) With normal or elevated PTH levels-

  1. Primary or tertiary hyperparathyroidism (most common)
  2. Li- induced hyperparathyroidism
  3. Familial hypocalciuric hypercalcemia

II) With low PTH levels-

  1. Malignancy (most common)
  2. Elevated 1, 25 (OH)2 vitamin D
  3. Thyrotoxicosis, sarcoidosis, bone metastasis, multiple myeloma
  4. Paget’s disease with immobilisation
  5. Milk- alkali syndrome
  6. Thiazide diuretics
  7. Glucocorticoids deficiency

Etiology-

  1. With normal or elevated PTH levels-
  2. Primary or tertiary hyperparathyroidism (most common)
  3. Li- induced hyperparathyroidism
  4. Familial hypocalciuric hypercalcemia

II) With low PTH levels-

  1. Malignancy (most common)
  2. Elevated 1, 25 (OH)2 vitamin D
  3. Thyrotoxicosis, sarcoidosis, bone metastasis, multiple myeloma
  4. Paget’s disease with immobilisation
  5. Milk- alkali syndrome
  6. Thiazide diuretics
  7. Glucocorticoids deficiency

Clinical features-

  • General- anorexia, fatigue, nausea, pancreatitis
  • Renal- polyuria, polydipsia, renal stones
  • GIT- dyspepsia, peptic ulcer, constipation
  • CNS- impaired cognition, hypertension
  • Metabolic- metastaticcalcification, bone pain, fracture, nephrocalcinosis

 Investigations-

  • Most common investigation is serum PTH level.
  • PTH increased- primary hyperparathyroidism
  • High plasma phosphate & alkali phosphatise- tertiary hyperparathyroidism
  • Low urine calcium excretion- FHH
  • Tests used to distinguish Primary Hyperparathyroidsm from Familial Benign Hypercalcemia- urinary calcium levels
  • Hypercalcemia in ECG is diagnosed by decreased QT interval.

Treatment-

  • Volume expansion- 4-6 lt. Intravenous saline
  • Hypercalcemia of malignancy – Zoledronic acid, pamidronate
  • 1, 25 (OH)2 D mediated hypercalcemia- glucocorticoids
  • Calcitonin- for life threatening hypercalcemia
  • Bisphosphonates- decreased serum calcium
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