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Time for some #SpacedRepetition: @CPSolvers May 21th Day 52: http://bit.ly/3bQKzTB
Chat recap of the #ClinicalPearls #VirtualMorningReport w/ @Sharminzi @ArsalanMedEd @tmodarressi Sonia Silinksy Krupnikova @mBohlega
Learning points: @Anand_88_Patel
@DxRxEdu @rabihmgeha
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,
1,25 -OH Vit D
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,
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?
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
more precipitous presentation of vascular dementia
depression, polypharmacy,
PO intake hyponatremia, infection, urinary retention
Could have had an infarct on top of chronic silent infarcts
more precipitous presentation of vascular dementiadepression, polypharmacy,
PO intake 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
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
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'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
Can hyperammonemia cause agitation? The short answer is yes. Sxm'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
Could this be a cortical or subcortical stroke? http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/NeurLrngObj_Stroke01new.htm
? low solute diet + alcohol = recipe for hyponatremia
Technically dehydration = hypernatremia
? low solute diet + alcohol = recipe for hyponatremia
Technically dehydration = hypernatremia
Let'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
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/
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/
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 altered elderly pts, do a good skin exam. Things can be hiding beneath clothes like ulcers, Shingles, cellulitis, hematomas
crypto gattii can present in immunocompetent hosts
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6906646/
In 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?
4 a chloride to phos ratio > 33 (reliable dx test for primary hyperPTH)
https://pubmed.ncbi.nlm.nih.gov/14964541/
Our ratio is 23.
could it be milk alkali from tums?
Hypercalcemia + elevated bicarb + aki -->?milk alkalai?
4 a chloride to phos ratio > 33 (reliable dx test for primary hyperPTH) https://pubmed.ncbi.nlm.nih.gov/14964541/
Our 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/
Another corresponding episode https://clinicalproblemsolving.com/2019/01/03/episode-7-hypercalcemia/
I want Vitamin D level 25 and 1,25 OH, PTH and PTH-rp please
https://clinicalproblemsolving.com/dx-schema-hypercalcemia/
Another corresponding episode https://clinicalproblemsolving.com/2019/01/03/episode-7-hypercalcemia/
multiple myeloma causes an alk phos when there are assoc fractures. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706085/
hypercalcemia 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 polyuria.
alk phos when there are assoc fractures. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706085/hypercalcemia 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
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
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)
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
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—‹ 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
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
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 is the Mesenteric lymphadenopathy? https://pubs.rsna.org/doi/full/10.1148/rg.252045108
What is the Mesenteric lymphadenopathy? https://pubs.rsna.org/doi/full/10.1148/rg.252045108
Hypercalcemia as a Rare Presentation of Angioimmunoblastic T Cell Lymphoma: A Case Report
https://pubmed.ncbi.nlm.nih.gov/29673407/
But 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/29673407/
But 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/
8.3% of sarcoidosis is extra-pulmonary only: https://pubmed.ncbi.nlm.nih.gov/29453944/
Lack of resolution with IVFs argues against milk alkali
A similar case to today's. A link to @medrants CPS reference from NEJM. https://www.nejm.org/doi/full/10.1056/NEJMcps0903034
Lack of resolution with IVFs argues against milk alkali
A similar case to today's. A link to @medrants CPS reference from NEJM. https://www.nejm.org/doi/full/10.1056/NEJMcps0903034
While certain tumors are more known to cause hypercalcemia, it can occur with almost any type of cancer. Hodgkin lymphoma is an infrequent cause of hypercalcemia. Here is another good free case review https://www.hindawi.com/journals/crionm/2019/4129349/
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