Hypercalcemia 

Introduction

Hypercalcemia is defined as a total calcium level in the plasma greater than 2.6 mmol/L. 

  • Mild hypercalcemia =  2.7 – 2.9 mmol/L
  • Moderate hypercalcemia = 3.0 – 3.4 mmol/L
  • Severe hypercalcemia = greater than 3.4 mmol/L

Causes

  • primary hyperparathyroidism
  • malignancy
  • excessive vitamin D intake
  • thiazides or renal failure (secondary hyperparathyroidism)
  • sarcoidosis
  • multiple myeloma
  • immobilization

Clinical presentation 

  • Mild hypercalcemia - may be asymptomatic, nonspecific symptoms, such as constipation, fatigue, and depression
  • Moderate hypercalcemia - polyuria, polydipsia, dehydration, anorexia, nausea, muscle weakness, and changes in sensorium
  • Severe hypercalcemia - lethargy, confusion, stupor, coma and progression of symptoms above

ECG manifestation 

  • short QT interval
  • ST segment may be completely absent and replaced by inverted small T-wave directly after R-wave
  • Osborn wave (usually a feature of hypothermia) - a positive deflection at the J point (negative in aVR and V1), most prominent in the precordial leads
  • J-point elevation mimicking ST segment elevation is a common observation
  • Ventricular irritability and VF arrest may occur in extreme hypercalcemia

 Picture 1 QT interval in serum calcium abnormalities 

https://litfl.com/hypercalcaemia-ecg-library/

  

Picture 2 Osborn wave

 

 ECG 1 Hypercalcemia (shortened QT interval, Osborn wave in V1) 

  
Management

 Treatment depends on the severity of symptoms and the underlying cause.

 avoid thiazide diuretics, prolonged inactivity, high calcium diet 

  • adequate hydration minimises risk of nephrolithiasis
  • saline hydration 
  • bisphosphonates
  • calcitonin

 References

  1. Kelwade JV, Modi KD, Kumar N, Parekh H. Hypercalcemia and electrocardiogram changes. Indian J Endocrinol Metab. 2016;20(6):892-893. doi:10.4103/2230-8210.192900
  2. Elizabeth Shane, Clifford J Rosen, Jean E Mulder.Diagnostic approach to hypercalcemia.: https://www.uptodate.com/contents/diagnostic-approach-to-hypercalcemia
  3. Elizabeth Shane, Clifford J Rosen, Jean E Mulder.Clinical manifestations of hypercalcemia
  4. Elizabeth Shane, Clifford J Rosen, Jean E Mulder. Treatment of hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia
  5. https://litfl.com/hypercalcaemia-ecg-library/
  6. https://www.techmed.sk/hyperkalcemia/
  7. https://www.uptodate.com/contents/clinical-manifestations-of-hypercalcemia