Critical Care: Student/Resident Case Report Poster - Critical Care II |

Parathyrotoxicosis: Far Beyond Overtones FREE TO VIEW

Oki Ishikawa, MD; Trisha Newaz, DO; Maria Peña, MD
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Lenox Hill Hospital, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):405A. doi:10.1016/j.chest.2016.08.418
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Hypercalcemic crisis involves the decompensation of patients in the setting of severe hypercalcemia. It typically occurs in those with chronic hypercalcemia, which in turn is most frequently caused by primary hyperparathyroidism. Presentation varies widely, including multi-organ dysfunction requiring intensive care. We present a case that illustrates not only the severity, but an uncommon circumstance for hypercalcemic crisis.

CASE PRESENTATION: A 79 year old female with a distant history of breast cancer presented with altered mental status. Patient was alert but nonverbal and was unable to follow commands. Family at bedside denied any other symptoms and also informed that she was diagnosed with dementia 6 months prior, with a rapid cognitive decline within the last 2 weeks. Initial physical exam was remarkable for hypotension, tachycardia, and epigastric tenderness. Labs were significant for lactate of 4.7, leukocytosis of 35K, lipase of 5372, calcium of 21mg/dL, pyuria, and BUN/Cr elevated from her baseline of 8mg/dL and 0.81 mg/dL, to 81mg/dL and 4.31mg/dL respectively. CT of the head was within normal limits. Hemodynamic stability was obtained after initial treatment for sepsis and pancreatitis. However she was admitted to the ICU for concerns of airway protection due to her severely depressed mentation. Renal function was only marginally improving at this point, and a decision was made to dialyze her for better improvement of her persistently elevated calcium level. Pamidronate and Calcitonin were also administered per endocrinology team recommendation. Concurrent workup revealed elevated serum PTH levels, and a CT scan of the neck showed a parathyroid mass. This was later localized with a sestamibi scan and she subsequently had a parathyroidectomy, which pathology revealed an adenoma. She was discharged shortly afterwards with her mental status at baseline and a normal calcium level.

DISCUSSION: Our patient’s acute cognitive decline, acute kidney injury, and pancreatitis were likely due to her severely elevated calcium level. In such cases, intensive care should be considered for multiorgan dysfunction and monitoring for further possible complications such as airway compromise. Another interesting point about this case is that her crisis occurred without a prior history of chronic hypercalcemia. Additionally, the pathology in this case returned as a parathyroid adenoma rather than a carcinoma, which the latter is more associated with this degree of hypercalcemia.

CONCLUSIONS: Severe hypercalcemia can detrimentally affect multiple organ systems thus requiring intensive care. Timely diagnosis with treatment is necessary.

Reference #1: Marcocci C, Cetani F. Primary Hyperparathyroidism. N Eng J Med. 2011; 365: 2389-2397

Reference #2: Ahmad S, Kuraganti G, Steenkamp D. Hypercalcemic Crisis: A clinical review. The American Journal of Medicine (2015) 128, 239-245

DISCLOSURE: The following authors have nothing to disclose: Oki Ishikawa, Trisha Newaz, Maria Peña

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