Category: Calcium/Bone Disorders

Monitor: 20

20 - Hypercalcemia: Immobilization vs End-Stage Liver Disease

Friday, Apr 26
12:00 PM – 12:30 PM

Objective :

Hypercalcemia (HCa++) in a hospitalized patient is usually secondary to malignancy. Less commonly, HCa++ can also result from hyperparathyroidism and granulomatous disease. An unusual cause of HCa++ is chronic liver disease which was first described in 1987 by Gerhardt. Lastly, HCa++ of immobilization can occur with prolonged bedrest and is a diagnosis of exclusion. A case of HCa++ of unknown etiology is presented with the differential diagnosis being immobilization vs. end-stage liver disease.


Methods : A 40-year-old female, bed bound for 3 months, with cirrhosis due to autoimmune hepatitis and PBC, who was an active liver transplant candidate and recently diagnosed with pulmonary Cryptococcus neoformans presented for nausea and vomiting. Labs were significant for a corrected Ca++ of 13.7 mg/dL (n: 8.8-10.2) and ionized Ca++ of 1.42 mmol/L (n: 1.12-1.32). Aggressive IV fluids and SQ calcitonin were given. Two days later, the Ca++ fell to 12.9mg/dL. PTH level was low at 17pg/mL (n: 15-65), 25 OHD was 18 ng/mL (n: 30-100). On day 5, the Ca++ level rose to 14.32 mg/dL. C. neoformans has been associated with HCa++, but the 1,25- OH VitD level was low at 11.2 pg/mL (n: 19.9-79.3). PTHrP was normal at 3.1pg/L (n: 0.0-3.4), ruling-out HCC. On day 6, the Ca+ peaked at 14.72 mg/dL. N-telopeptide was elevated at 178 (n: 4-64 nmol BCE) which is consistent with enhanced osteoclast activity. Pamidronate was given. Three days later, the Ca++ decreased to 9.08 mg/dL and continued to drop prompting therapy with CaC03 and calcitriol. On day 17, the patient received a liver transplant. CaC03 and calcitriol were tapered off two days after transplantation as the Ca++ levels normalized. Three weeks after discharge, the patient’s Ca++ level remained at 8.3 mg/dL.


Results : n/a


Discussion : This complex case elucidates the rare causes of hypercalcemia.  We believe the degree of this patient’s acute immobilization could explain her HCa++.  Additionally, end-stage liver disease is a rare cause of hypercalcemia with only case series documenting this phenomenon. The postulated mechanism is that inflammatory substances like TNF-1, osteoclast-activating factor, and IL-1, are released in liver disease which stimulate osteoclasts to release Ca++ from bones. Therefore, osteoclastic bone breakdown appears to play a role in both immobilization and end stage liver disease and will both respond to pamidronate. In this case, the patient’s Ca++ levels were sustained in the normal ranges two weeks after her liver transplant and five weeks after receiving pamidronate. Thus, it is plausible that both end-stage liver disease and immobilization contributed to this patient’s HCa++.


Conclusion : n/a

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Jessica Chan

Endocrinology Fellow
LAC+USC Medical Center

Jessica Chan graduated from UCSD in 2010 with a BA in Human Development. She went on to graduate from Creighton University School of Medicine in 2015 and trained at Lenox Hill Hospital in NYC for Internal Medicine residency. She is now a first year Endocrine Fellow at USC. She became ABIM certified in Aug 2018.

Michael Cruz

Endocrinology Fellow
LAC + USC
Alhambra, California

POST-GRADUATE TRAINING
 FELLOWSHIP July 2017–July 2019
Endocrinology, Los Angeles County + University of Southern California
 RESIDENCY June 2014–June 2017
Internal Medicine, Santa Clara Valley Medical Center

EDUCATION
 DOCTOR OF MEDICINE June 2014
University of California, San Diego School of Medicine
 MASTER OF ADVANCED STUDIES IN CLINICAL RESEARCH June 2013
University of California, San Diego
 BACHELOR OF SCIENCE BIOPSYCHOLOGY MAJOR December 2008
University of California, Santa Barbara
 BACHELOR OF ARTS SPANISH MINOR December 2008
University of California, Santa Barbara

BOARD CERTIFICATION
 American Board of Internal Medicine August 2018

Jon Lopresti

Director Thyroid Clinic, Program Director of Endocrinology Fellowship Program
LAC+USC Medical Center

A native of Los Angeles, Dr. LoPresti received both his medical degree and his Ph.D. in physiology from the University of Southern California.

He first joined the Trojan family in 1974 as a biology undergraduate and finished his residency at the LAC+USC Medical Center ten years later. Dr. LoPresti has contributed to over fifty presentations, recently lecturing on a case of an aggressive Papillary Thyroid Cancer arising in the third trimester of pregnancy. In addition, he has had leadership roles in the American Thyroid Association and has been published in numerous journals, abstracts and book chapters. He serves as the program director of the endocrinology fellowship program and is the director of the thyroid clinic.

Jessica Chan

Endocrinology Fellow
LAC+USC Medical Center

Jessica Chan graduated from UCSD in 2010 with a BA in Human Development. She went on to graduate from Creighton University School of Medicine in 2015 and trained at Lenox Hill Hospital in NYC for Internal Medicine residency. She is now a first year Endocrine Fellow at USC. She became ABIM certified in Aug 2018.