The milk alkali syndrome was well known in the pre-proton pump inhibitor era when remedies for peptic ulcer included a large amount of calcium and sodium bicarbonate resulting in hypercalcaemia, metabolic alkalosis and often acute kidney injury. In a study done from 1998 to 2003, milk alkali syndrome was the cause of hypercalcaemia in 8.8 percent of the cases which is a significant percentage, so awareness about it is important.
We present a 76 year old gentleman who developed milk alkali syndrome inadvertently. He was admitted under urology for surgery on his bladder tumour but had a prolonged stay due to surgical complications. His background illness included hypertension, psychosis and depression. He was on no offending medications.
He was started on milk 200 ml TDS following advice from dietitians. He developed hyperkalaemia and acute kidney injury which was treated with intravenous fluids and Calcium gluconate. His Calcium, which was normal pre-admission, increased with and this thought to be secondary to the IV calcium. His hyperkalaemia was persistent and he was started on oral sodium bicarbonate. Calcium level increased to 3.41 after this.
Other results showed a suppressed PTH, normal phosphate, low Vitamin D level and pH of 7.33. We stopped both the milk and the oral bicarbonate and continued IV fluids for 48 hours, which resulted in normalisation of calcium level. He was also treated with cholecalciferol, although the suppressed PTH suggested the hypercalcaemia was unrelated to the Vitamin D deficiency.
This case highlights the importance of a good medications review and considering rarer causes of hypercalcaemia. With the increase in use or oral caclium in the management of osteoporosis and its easy availabitlity over- the -counter use, we should consider milk alkali syndrome as a cause of hypercalcaemia, especially with a suppressed Parathyroid hormone level.