Severe Hypercalcaemia can present as a life threatening emergency requiring urgent measures to lower the calcium. Usually, this is associated with Primary Hyperparathyroidism. It can result in obtundation, oliguria, anuria, collapse or arrhythmias. It is important to act fast and decisively to prevent fatal complications.
We describe a 39 year old gentleman who was a tennis coach, who was brought after he collapsed in his bathroom. He had a 3-month history of lethargy, dry cough, light headedness and a stone of weight loss but able to work and in fact had done tennis lessons till the previous day. He also had a weeks history of increasing lethargy, anorexia, and several fainting episodes. He had no past medical problems and was not on any regular medications or over the counter supplements.
On examination, he was alert but appeared dehydrated. His veinous gas showed a high ionized calcium and the lab confirmed a very high calcium level of 4.82. His Parathyroid hormone level was off the scale at >250 pmol/l.
He was admitted to ITU and received IV Fluids, Bisphosphonate, and calcitonin for 48 hours. But the calcium was still high and he underwent haemofiltration (Continuous Veino-Veinous Hemofiltration) and Cinacalcet was introduced. He had an urgent ultrasound of his neck which showed a large right parathyroid gland. He had emergency 3 glands parathyroidectomy on day 4.
He became profoundly hypocalcaemic after surgery and needed regular IV calcium top ups despite being on good doses of alfacalcidol and oral calcium to alleviate hypocalcaemic symptoms. He went home with some element of kidney damage.
This case highlights aggressive and early measures to reduce calcium and good supportive care in a controlled environment will result in good patient outcomes.