Time for some #SpacedRepetition: @CPSolvers May 21th Day 52: http://bit.ly/3bQKzTB ">https://bit.ly/3bQKzTB&q...

Chat recap of the #ClinicalPearls #VirtualMorningReport w/ @Sharminzi @ArsalanMedEd @tmodarressi Sonia Silinksy Krupnikova @mBohlega

Learning points: @Anand_88_Patel

@DxRxEdu @rabihmgeha
Problem Representation:

A 92 year old M veteran with a h/o of Afib on AC & BPH p/w with acute on subacute altered mental status and personality changes, agitation, & dizziness. Physical exam reveals dry MM & lethargy but otherwise along w/ hypercalcemia, AKI, https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔼" title="Up-pointing triangle" aria-label="Emoji: Up-pointing triangle">1,25 -OH Vit D
It’s MIST time! with UTI being top on the differential classically in this elderly male who is set up for urinary retention

UTI - often blamed, rarely the cause

meds meds meds: Polypharmacy!

wondering if he’s wobbly wacky and wet?
A sharp decline in executive dysfunction could point us towards vascular dementia

Could have had an infarct on top of chronic silent infarcts https://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Right-pointing triangle" aria-label="Emoji: Right-pointing triangle"> more precipitous presentation of vascular dementia

depression, polypharmacy, https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">PO intakehttps://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Right-pointing triangle" aria-label="Emoji: Right-pointing triangle"> hyponatremia, infection, urinary retention
The rapid decline for any kind of neurodegenerative disease, I think more delirium here

once declines in function become chronic, then we think dementia is more likely, but subacute can be delirium...but characteristically delirium is waxing and waning
Always look for the reversible causes: infection, metabolic, bleeds, endocrine, meds

Thinking metabolic: b12 def, hypo or apathetic hyperthyroidism, hyperCa, wernicke

Lewy Body Dementia can sometimes present more as delirium…and is very sensitive to decompensation from meds
Hyperammonemia can do much of this along with subacute subdural hematomas

Can hyperammonemia cause agitation? The short answer is yes. Sxm& #39;s are nonspecific w/ ataxia, vomiting, focal neuro findings, low-grade fever, drowsiness, lethargy, agitation. https://www.tandfonline.com/doi/pdf/10.1080/24750573.2018.1448133">https://www.tandfonline.com/doi/pdf/1...
Could this be a cortical or subcortical stroke? http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/NeurLrngObj_Stroke01new.htm

?">https://casemed.case.edu/clerkship... low solute diet + alcohol = recipe for hyponatremia

Technically dehydration = hypernatremia
Let& #39;s call it volume-depleted instead of dehydrated

Classic hypercalcemia history is polyuria, constipation, &confusion

lethargic & dry mouth: worry a little about anti-cholinergic but more likely dehydration

Love the pearl “a little bit off” = encephalopathic = think global
lead toxicity due to retained bullet?

Lead intoxication = plumbism

Subtle findings such as the occurrence of unexplained anemia, abdominal colic, nephropathy, or neurologic deterioration in patients w/ retained missiles = plumbism. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352636/">https://www.ncbi.nlm.nih.gov/pmc/artic...
Crypto = headache usually and then routine findings if not immunosuppressed.

crypto gattii can present in immunocompetent hosts
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6906646/

In">https://www.ncbi.nlm.nih.gov/pmc/artic... altered elderly pts, do a good skin exam. Things can be hiding beneath clothes like ulcers, Shingles, cellulitis, hematomas
The ball drops...HyperCa!!!! cancer until proven otherwise

could it be milk alkali from tums?

Hypercalcemia + elevated bicarb + aki -->?milk alkalai?

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✅" title="White heavy check mark" aria-label="Emoji: White heavy check mark">4 a https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔼" title="Up-pointing triangle" aria-label="Emoji: Up-pointing triangle"> chloride to phos ratio > 33 (reliable dx test for primary hyperPTH)
https://pubmed.ncbi.nlm.nih.gov/14964541/ 

Our">https://pubmed.ncbi.nlm.nih.gov/14964541/... ratio is 23.
myeloma? sodium is normal though. with paraproteins it could be falsely low

I want Vitamin D level 25 and 1,25 OH, PTH and PTH-rp please

https://clinicalproblemsolving.com/dx-schema-hypercalcemia/">https://clinicalproblemsolving.com/dx-schema...

Another corresponding episode https://clinicalproblemsolving.com/2019/01/03/episode-7-hypercalcemia/">https://clinicalproblemsolving.com/2019/01/0...
multiple myeloma causes an https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔼" title="Up-pointing triangle" aria-label="Emoji: Up-pointing triangle">alk phos when there are assoc fractures. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706085/

hypercalcemia">https://www.ncbi.nlm.nih.gov/pmc/artic... leads to dehydration through it causing polyuria

Polyuria in adults is defined as urine output more than 3 L/d (>40 mL/kg/d).

Up to 20% of pts w/ hyperCa https://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Right-pointing triangle" aria-label="Emoji: Right-pointing triangle">https://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Right-pointing triangle" aria-label="Emoji: Right-pointing triangle"> polyuria.
The postulated mechanism is downregulation of aquaporin-2 water channels, and calcium deposition in the medulla with secondary tubulointerstitial injury, leading to impaired generation of the interstitial osmotic gradient. https://www.amjmed.com/article/S0002-9343(18)31029-5/fulltext">https://www.amjmed.com/article/S...
nephrogenic DI - interferes with ADH attaching to aqua-Orin 2

Remember normal PTH is abnormal in this situation

Good mnemonic for bone mets: BLT sandwich with a Kosher Pickle (breast, lung, thyroid, kidney, prostate)
so cancer and milk alkali will cause similar lab pattern. stopping tums will help differentiate both before embarking on malignancy workup

so now we have the PTH low, PTH-RP low, low VitD

sarcoid vs lymphoma?

Constipation classic for hypercalcemia
Hormonal :
â—‹ PTH: primary, secondary, tertiary hyperparathyroidism
â—‹ PTHRp: renal cell carcinoma or squamous
â—‹ Vit D: increase intake of 25oh , or granuloma producing vit D like substance Lytic processes
â—‹ Lytic bone diagnoses: lung, breast, multiple myeloma
â—‹ Milk alkali
â—‹ Meds: HCTz, lithium
â—‹ Endocrine: increased T4, decreased adrenal
- Tums: alkalosis and AKI and hypercalcemia
o Third MC cause of hypercalcemia
o Each tum is 0.5 grams. Usually need 3-4 grams to get milk alkali
The nodes are likely a clue - 1,25 D is borderline high

Tissue is the issue?

@medrants notes that Lymphoma can do this

as well as Granulomatous process such as sarcoid, histo, blasto

bone & lungs lesions suggestive of sarcoid or disseminated histo/blasto
why would steroids treat hypercalcemia? Steroids inhibit 1-α-hydroxylase conversion of 25-hydroxyvitamin D (calcidiol) into 1,25-dihydroxyvitamin D (calcitriol) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4675637/

What">https://www.ncbi.nlm.nih.gov/pmc/artic... is the Mesenteric lymphadenopathy? https://pubs.rsna.org/doi/full/10.1148/rg.252045108">https://pubs.rsna.org/doi/full/...
Hypercalcemia as a Rare Presentation of Angioimmunoblastic T Cell Lymphoma: A Case Report
https://pubmed.ncbi.nlm.nih.gov/29673407/ 

But">https://pubmed.ncbi.nlm.nih.gov/29673407/... what about sarcoid and no lung involvement? Is that a thing? Clinical Features of Extrapulmonary Sarcoidosis Without Lung Involvement https://pubmed.ncbi.nlm.nih.gov/29453944/ ">https://pubmed.ncbi.nlm.nih.gov/29453944/...
8.3% of sarcoidosis is extra-pulmonary only: https://pubmed.ncbi.nlm.nih.gov/29453944/ 

Lack">https://pubmed.ncbi.nlm.nih.gov/29453944/... of resolution with IVFs argues against milk alkali

A similar case to today& #39;s. A link to @medrants CPS reference from NEJM. https://www.nejm.org/doi/full/10.1056/NEJMcps0903034">https://www.nejm.org/doi/full/...
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