73 year-old Female with Hypercalcemia
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1 73 year-old Female with Hypercalcemia Katie O Sullivan, M.D. Fellow, Adult/Pediatric Endocrinology University of Chicago Thursday, December 19 th, 2013
2 Chief Complaint 73 year-old female who presents for further evaluation of hypercalcemia.
3 History of Present Illness 73 year-old female with no significant past medical history Generally feeling unwell for 1 year Generalized weakness Dizziness, light-headedness Poor appetite, 15-lb weight loss over past 10 months Forgetful x 1 month Polydipsia, dehydrated Urinary frequency/incontinence for past 2 years Intermittent bone pain/low back pain
4 Past Medical History Depression/Anxiety Acutely worsen 10 months ago following a lifethreatening injury to daughter-in-law Panic attacks Receiving psychotherapy, no medical management
5 Follows regularly with internist at U of C for several years Established care with an alternative health care provider in NYC 7 months ago Several $1000 s discounts applied Several therapies offered -> excellent compliance with therapies
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7 Supplements/Therapies Ergocalciferol 50,000 units weekly Cholecalciferol 5,000 units daily Forteo x 1 dose (could not afford more) Magnesium 470mg daily Strontium daily Thyroid hormone 15mg daily
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9 Rest of History PMHx: Multiple Thyroid Nodules: stable over 1 year Glaucoma Osteoporosis: 6/2013 OB/Gyne History: Periods of infertility Medications: Aspirin 81mg daily Multivitamin daily Brimonidine tartrate 0.1% eye gtt Social History: Widow Holds several advanced degrees Family History: Post-menopausal sister with fragility fracture No history of hypercalcemia, osteoporosis, or hyperparathyroidism
10 Review of Systems Page 1 Constitutional: No fevers. No night sweats. Weight loss - 15# since 1/2013. Polydipsia. Psychiatric: Depression/Anxiety. Eyes: Glaucoma. Nose/Mouth/Throat: No congestion. No rhinorrhea. No sore throat. Neck: No neck swelling or pain. No hoarseness. No dysphagia. Cardiovascular: No chest pain. Palpitations. No lower extremity edema.
11 Review of System Page 2 Respiratory: Dyspnea on exertion x 1 year with anxiety. No orthopnea. No cough. Gastrointestinal: Poor appetite. No abdominal pain. No diarrhea. No constipation. No nausea. No vomiting. Genitourinary: Frequency. Nocturia twice/night. Incontinence - worse in last 2 years. Skin: Rash on left arm. Neurologic: No tremor. Headache - rare. Weakness. Intermittent lightheadedness. Dizziness. Musculoskeletal: Bone pain in the right knee, worse with dancing. Intermittent midline low back pain. No history of fractures.
12 Physical Examination Vitals: P 103, BP 107/69, Wt 50.4kg, Ht cm, BMI General: Appears thin, frail, older than stated age. Scattered historian. Eyes: Conjunctiva and extra-ocular movements normal. PERRL. Mouth/Throat: Dry mucous membranes. Oropharynx is clear Neck: Supple, no adenopathy. Mild symmetrically-enlarged thyroid. No thyroid nodules appreciated Cardiovascular: Tachycardic. No murmur. Radial pulse 2+. No lower extremity edema.
13 Pulmonary: Lungs CTAB Abdomen: Soft, normal bowel sounds, non-tender, nondistended. No masses or HSM. MSK: FROM, No tenderness. Mild kyphosis. Neurological: Alert and oriented. Patellar reflex 1+ bilaterally. Normal muscle tone. Skin: No rash. No alopecia. +Mild hirsutism with hair on chin Psychiatric: Anxious. Tearful, especially went recounting her family member s injury.
14 Differential Diagnosis?
15 Differential Diagnosis of Hypercalcemia
16 Current Laboratory Studies Calcium: 14.3 mg/dl 141 ica: 7.6 mg/dl Phosphate: 2.2 mg/dl 5.5 PTH: 291 pg/ml Vitamin D 25-OH: 100 ng/ml GFR: 70 ml/min CBC: WBC 6.8, Hgb 13.1, Plt 217 TSH 0.32, Free T
17 Calcium Trend
18 Calcium/PTH Trend
19 Next Step: Hospitalization Treatment: Aggressive hydration with NS at 200cc/hr Cinacalcet 60mg daily Calcium improved: 10.9 mg/dl Discharged with Cinacalcet ED Visit 1 week later, Calcium 12.8 mg/dl s/p NS bolus, discharged with Cinacalcet
20 Parathyroid Imaging
21 Surgical Procedure: 11/26/13 Unilateral exploration Enlarged right upper parathyroid at the middle portion of the thyroid. The right lower parathyroid was seen and appeared normal. Right Upper Parathyroidectomy Pathology: Enlarged, hypercellular parathyroid (390 mg). Intraoperative PTH Monitoring: Pre 1/2: 335/474 5 min: min: 70 25min: 19
22 Post-Operative Follow-Up Presentation Calcium: 14.3 mg/dl PTH: 291 pg/ml ica: 7.6 mg/dl Phosphate: 2.2 mg/dl Vitamin D 25-OH: 100 ng/ml Post-Parathyroidectomy Calcium 9 mg/dl PTH 19 pg/ml Vitamin D 25-OH: 40 ng/ml
23 Diagnosis Hypercalcemia secondary to primary hyperparathyroidism while on high-dose Vitamin D replacement
24
25 Clinical Questions What is the standard of care for treatment of Vitamin D deficiency among alternative health care providers? What is appropriate treatment of Vitamin D deficiency in the setting of primary hyperparathyroidism?
26
27 Alternative Health Philosophy
28 Alternative Health Philosophy Assessment of Vitamin D 25-OH Levels: Minimum : 80nmol/L = 32ng/mL Optimum : nmol/l (50-70ng/mL) in Caucasians, nmol/l (32-48 ng/ml) in AA Safe Upper Limit : 250nmol/L (100ng/mL) Treatment of Vitamin D Deficiency: Loading Dose : 20,000 IU (?time) for 3-6 months Maintenance Dose : 5,000 IU/day Caution: Sarcoidosis, drug interactions ( diuretic ), Vitamin A, D, K2 interaction Summary: Increase dosage 4-10 times the current RDI recommendations Integrative Medicine 2010
29 Goal Vitamin D 25-OH: >30ng/mL Vitamin D Replete: Maintenance for > 70yo: IU/d Vitamin D Deficient: Treatment: 50,000IU/week or 5,000IU/dx 8 weeks Maintenance: 1,000-2,000IU/d (2-3x higher if obese or malabsorption) Holick et al. JCEM. 2011
30 Clinical Questions What is the standard of care for treatment of Vitamin D deficiency among alternative health care providers? What is appropriate treatment of Vitamin D deficiency in the setting of primary hyperparathyroidism?
31 Vitamin D Deficiency and Primary Hyperparathyroidism (PHPT) 27-93% of patients with PHPT are Vitamin D deficient 1 Vitamin D deficiency exacerbates biochemical phenotype of PHPT as well as hungry bone syndrome in post-surgical pts 2 Treatment of Vitamin D Deficiency 3,4,5 : Reduce PTH levels Reduce markers of bone turnover Improved bone mineral density 1.Silverberg et al. American Journal of Medicine Stewart et al. Surgery Silverberg. J Bone and Mineral Research Grey et al. JCEM Tucci, JR. European Journal of Endocrinology 2009.
32
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34 Treatment of Vitamin D Deficiency in PHPT For patients with primary hyperparathyroidism and Vitamin D deficiency, we suggest treatment with vitamin D as needed. Serum calcium levels should be monitored. Suggested (Level 2) with high-quality evidence. Holick et al. JCEM. 2011
35 Conclusion Use of over-the-counter supplements can be dangerous if not used properly Vitamin D deficiency is not uncommon among patients with PHPT Vitamin D deficiency exacerbates the phenotype of PHTP and should be treated Treatment of Vitamin D deficiency in patients with PHTP is safe, but requires close monitoring of calcium
36 Works Cited 1) Grey et al. Vitamin D Repletion in Patients with Primary Hyperparathyroidism and Coexistent Vitamin D Insufficiency. JCEM. 2005;90(4): ) Holick et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline. JCEM. 2011; (96)7: ) Pizzorno, J. What Have We learned About Vitamin D Dosing? Integrative Medicine (1):8. 4) Silverberg et al. Effects of Vitamin D insufficiency in patients with primary hyperparathyroidism. American Journal of Medicine. 1999;107: ) Silverberg, Shonni. Vitamin D Deficiency and Primary Hyperparathyroidism. Journal of Bone and Mineral Research. 2007; 22(2): ) Stewart et al. 25-hydroxyvitmain D deficiency is a risk factor for symptomatic postoperative hypocalcemia and secondary hyperparathyroidism after minimally invasive parathyroidectomy. Surgery. 2008; 138(6): ) Tucci, JR. Vitamin D therapy in patients with primary hyperparathyroidism and hypovitaminosis D. European Journal of Endocrinology. 2009; 161:
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