Abstract 88: Missed hypercalcaemic crisis: Need for awareness

Background: Hypercalcemia is arelatively common conditionin hospital settings, etiology being malignancies, symptomatic PHPT and granulomatous diseases. Still, it is under evaluated in clinical practice. Awareness amongst practitioners regarding evaluation and management is far more less. We are here to report two such cases of missed hypercalcaemic crisis, where more endocrine awareness would have helped managing patients. Methods: First case was a 54-year-old male, who presented to general practitioner with complaints of fever, weight loss, abdominal distention, and inconsolable cry for last 3-4 months. He was found to have raised ESR (82 mm/hr), raised calcium (14.1 mg/dl), ascites on USG abdomen and right upper zone infiltrates on chest radiography. Ascitic tap suggested low serum albumin, ascitic fluid albumin gradient and raised adeno-deaminase, in view of which he was started on ATT. Contrast enhanced MRI brain was normal. His neurological symptoms did not improve after 15 days of treatment. He presented to us with these complaints, diagnosis was reconfirmed but he was found to have persistent hypercalcemia (14.2 mg/dl), normal phosphate (4.5 mg/dl) and raised creatinine (1.4 mg/dl). On further evaluation, he had PTH independent hypercalcemia (6 pg/ml) with raised 1,25 (OH)D. A diagnosis of hypercalcemic crisis secondary to active tuberculosis was made and patient was given iv zoledronic acid and started on methylprednisolone. Over next one week, calcium and creatinine improved to 9.9 mg/dl and 0.9 mg/dl. Patient's neuropsychiatric symptoms improved markedly with improvement of serum calcium. Second case, 56-year-old female who was on hemodialysis for 3 months after being diagnosed chronic kidney disease, presented to us with complaints of altered sensorium for last 1 day. She was evaluated and found to have persistent hypercalcemia (14.1 mg/dl, 14 mg/dl), raised phosphate (5.5 mg/dl) and creatinine (6.5 mg/dl). She was found to have PTH independent hypercalcemia (PTH 3 pg/ml, raised 1,25 (OH)D). Further, myeloma workup and bone marrow biopsy revealed positive M band, raised kappa lambda free light chain ratio and bright CD 38 positivity. Bone marrow also confirmed the diagnosis of multiple myeloma (30% plasma cells). Meanwhile, she underwent dialysis, started on dexamethasone and single dose of denosumab was given with which calcium improved and sensorium of the patient improved. Conclusions: Though hypercalcemia is not an uncommon finding in clinical practice but its evaluation is seldomdone. More awareness is needed for the evaluation and management of hypercalcemia.