Poster Abstract Abstract

(Adults - Parathyroid/Bone & Calcium Metabolism), #220515069328

Severe hypercalcaemia of hyperparathyroidism with cardiac compromise; avoiding dialysis with aggressive medical therapy

Abdullah Shamshir Abd Mokti, Endocrine unit, Medical Department, Hospital Tengku Ampuan Afzan, Kuantan; Raja Nurazni Raja Azwan, Endocrine unit, Medical Department, Hospital Tengku Ampuan Afzan, Kuantan

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012-9911366

Introduction

Severe hypercalcaemia of primary hyperparathyroidism (pHPT) is usually symptomatic and carries high mortality risk due to cardiac arrhythmia and decompensation. Treatment involves vigorous hydration alongside anti-resorbtive agents such as bisphophanate and RANK-Ligand inhibitor i.e denosumab. Usually, serum calcium of more than 4 mmol/l necessitates dialysis . Here, we report a case of severe hypercalcaemia of hyperparathyroidism with cardiac compromise treated medically resulted in avoidance of dialysis.

Methods

Case report

Results

The case is a 50-year old lady with hypertension, and chronic kidney disease stage IIIB who was diagnosed with primary hyperparathyroidism since 2020. She was stable with mild hypercalcaemia (calcium less than 3.0 mmol/L). During endocrine follow-up, she complained of constipation, abdominal discomfort, lethargic and vomiting for 2 weeks. She denied chronic cough, no constitutional symptoms, no bone pain, no recent fracture or immobilisation and she denied taking any supplementations. Clinical assessment done was in keeping with severe dehydration.

Blood investigations revealed severe hypercalcaemia (5.01mmol/L) with normal phosphate and acute on chronic kidney injury (urea 11, Creatinine 191). Electrocardiography showed first degree heart block, with shortened QT interval, heart rate 60-80 bpm.

Hydration with 5 litres of normal saline and intravenous denosumab was given. Nephrology team was consulted, but no dialysis was planned.

Hydration was increased to 6 litres/day on day 3 alongside intravenous frusemide to induce forced diuresis and calcium level reduced to 3.1 mmol/L after a week of admission. Repeated ECG showed resolved heart block and resolved shortened QT. Right inferior parathyroidectomy was done after localisation 2 weeks later and histopathyology confirmed parathyoroid adenoma.

Conclusion

Severe hypercalcaemia of pHPT can be treated with medical treatment and avoidance of dialysis if possible with aggressive treatment and close monitoring .Such patient should undergo parathyroidectomy as soon as possible.

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