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USMLE RX BRICKS endocrine 2 STEP 1
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HypercalcemiaLast Updated: November 8, 2022
access_time17 min
Learning Objectives (5)
After completing this brick, you will be able to:
● Define hypercalcemia and the normal calcium reference range.
● Describe how hypercalcemia presents, including the physiologic
effects of hypercalcemia on nerves, muscle cells, and cardiac
conduction.
● List the main causes of hypercalcemia and describe the underlying
mechanism of each.
● Describe how to diagnose hypercalcemia, including clinical and
laboratory findings.
● Outline the management of hypercalcemia, differentiating symptomatic
from asymptomatic patients.
CASE CONNECTION
TG is a 67-year-old former smoker who came in with cough and
abdominal pain and has just been diagnosed with lung cancer. He was
planning to retire at the end of the year but wonders whether he
should do it sooner because he is struggling to get through a workday.
He feels tired, and his bones hurt. You review his lab results and note
an elevated serum calcium level. “What about the pain in his bones?
Does that mean the cancer has already spread?” his wife asks.
,How will you explain the bone pain to TG and his wife? Consider
your answer as you read, and we’ll revisit at the end of the brick.
What Is Hypercalcemia?
Hypercalcemia is defined as having too much calcium in your blood.
The typical calcium serum reference range is 8.4-10.2 mg/dL, so 10.3
mg/dL or greater is considered hypercalcemia. As we’ll see,
hypercalcemia can be due a range of problems, including endocrine
issues (high parathyroid hormone), cancer, even immobility. And the
symptoms range widely, from none to marked confusion and
metabolic abnormalities. It’s a good test of your diagnostic skills, so
let’s investigate further.
How Does a Patient With
Hypercalcemia Present?
Signs and symptoms of hypercalcemia vary depending on disease
severity and how fast the disease arises:
● Most cases of hypercalcemia are chronic and asymptomatic.
This form is most often due to primary hyperparathyroidism.
● Acute hypercalcemia is generally symptomatic when the
calcium level exceeds 12 mg/dL and is most often seen in
patients with cancer.
,When symptoms do exist, they can appear anywhere in the body
that’s affected by high serum calcium levels, notably the nervous
system, GI tract, kidney, bones, and skeletal muscles.
Nervous System
Patients with hypercalcemia may exhibit central nervous system or
psychiatric effects. These include lethargy, confusion, or even coma
when levels exceed 14 mg/dL. Anxiety and depression are described
in patients with chronic hypercalcemia.
Gastrointestinal System
Hypercalcemia may cause constipation, anorexia, vomiting, loss of
appetite, and acute pancreatitis. High serum calcium can increase the
level of gastrin, which increases gastric acid production. Ultimately,
this may lead to peptic ulcer disease or gastritis.
Urinary System
Chronically high urine calcium levels may lead to calcium kidney
stones, causing flank pain, groin pain, and hematuria.
, Hypercalcemia is also a cause of polyuria and nephrogenic diabetes
insipidus, because high calcium inhibits the action of antidiuretic
hormone in the renal tubules. The high urine output associated with
diabetes insipidus will also cause polydipsia (abnormal increase in
thirst).
Hypercalcemia can also cause distal renal tubular acidosis (type 1
RTA) and acute kidney injury.
Musculoskeletal System
Chronic hypercalcemia (due to hyperparathyroidism) is associated
with mild muscle weakness, bone pain, osteopenia, and fractures.
These effects are usually due to an increase in osteoclast activity.
Findings from these systems are sometimes summarized (in no
particular order) as moans (nervous system), groans (digestive
system), stones (urinary system), and bones (musculoskeletal) (Figure
1).
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