Hypercalcemia: A Review

Dietary Supplement Safety in Older Adults: A Review of Published Case Reports

Objective: This review summarizes recent case reports where the consumption of dietary supplements by older adults may have caused an adverse event. Data Sources: In December 2023, PubMed was surveyed for case reports published from 2000 onwards, using two medical subject heading (MeSH) terms, "aged" and "dietary supplements," where the latter was combined with the MeSH subheadings "adverse effects," "poisoning," or "toxicity." Major clinical trials for dietary supplements were identified at ClinicalTrials.gov, an online database of clinical research studies, or in PubMed, and screened for information on adverse effects. Data Synthesis: The described search strategy yielded 820 publications, including 122 case reports, which were then manually screened for relevant and informative case reports involving dietary supplements and people 65 years of age or older. Consequently, 41 publications were selected describing 46 individual case reports. Etiologies of adverse events included interactions of dietary supplements with prescribed medication, ingestion of higher-than-intended or instructed supplement doses, intake of the same supplement from multiple sources, and supplement contamination. Prominent adverse events encompassed hypercalcemia (vitamin D), thyroid test interference (vitamin B7), neuropathy (vitamin B6), oxalate nephropathy (vitamin C), and interactions with warfarin therapy (vitamins E and K, and omega-3 fatty acids). Conclusion: Health care practitioners are advised to consider dietary supplements as contributors to adverse clinical symptom presentations, while patients are encouraged to provide current records of their prescribed medications and dietary supplements to their health care providers. This is particularly important for older adults where both medication intake and supplement consumption are high.

Uncovering Hypercalcemia of Malignancy Following Parathyroidectomy for Hyperparathyroidism

Hypercalcemia is a common complication of malignancy, often attributed to elevated PTH-related protein levels mimicking the effects of PTH and promoting bone resorption. We present the case of a 67-year-old Hispanic female with a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, and chronic kidney disease, who initially underwent parathyroidectomy for suspected primary hyperparathyroidism resulting from persistent hypercalcemia. Despite surgery, the patient continued to experience hypercalcemia and was subsequently diagnosed with diffuse large B-cell lymphoma with hypercalcemia as a rare but life-threatening complication. This case highlights the importance of considering malignancy as a potential cause of hypercalcemia, particularly in the context of hematologic malignancies such as diffuse large B-cell lymphoma. Prompt recognition and management are crucial to prevent severe complications associated with hypercalcemia. A multidisciplinary approach involving oncologists, endocrinologists, and supportive care teams is essential for effective management in such cases.

Calcitriol-Mediated Hypercalcemia Due to Liver Metastases in a Patient With Primary Pancreatic Neuroendocrine Tumor

Hypercalcemia is most commonly associated with primary hyperparathyroidism or malignancy in the setting of elevated parathyroid hormone-related protein or bone metastases. Calcitriol (1,25-dihydroxyvitamin D)-mediated hypercalcemia is rare and typically associated with granulomatous conditions; however, other solid-organ etiologies have been reported. Here, we detail the case of a 62-year-old man with metastatic pancreatic neuroendocrine tumor (pNET) with hypercalcemia refractory to traditional bisphosphonate therapy in the setting of vastly elevated 1,25-dihydroxyvitamin D. Only after initiation of chemotherapy with capecitabine and temozolomide did his serum calcium consistently improve and 1,25-dihydroxyvitamin D begin to decrease. There are fewer than 5 reported cases of a pNET resulting in calcitriol-mediated hypercalcemia. Prompt initiation of treatment for the underlying condition can result in a significant improvement in serum calcium or 1,25-dihydroxyvitamin D. Multiple reports have also demonstrated success with high-dose steroid administration in patients with other solid-organ etiologies of calcitriol-mediated hypercalcemia, but this has not yet been reviewed in the pNET population.

Severe, Symptomatic Hypercalcemia Secondary to PTH-secreting Pancreatoblastoma

Hypercalcemia may be induced by a variety of etiologies, most commonly primary hyperparathyroidism. Although primary hyperparathyroidism represents a relatively common endocrinological disorder, ectopic PTH secretion is a rare entity that is less well described in literature. We describe the first case to our knowledge of severe, symptomatic hypercalcemia found to be secondary to a PTH-secreting pancreatoblastoma. The patient initially presented with fatigue and progressive upper extremity intermittent muscular twitching. He was found to have biochemical evidence of primary hyperparathyroidism. A computed tomography scan of the neck and a sestamibi nuclear scan failed to definitively demonstrate a parathyroid adenoma or hyperplasia and bilateral surgical parathyroid exploration was unrevealing for any pathology. Abdominal imaging via computed tomography was obtained for evaluation of progressive postoperative epigastric pain, and the patient was found to have a retroperitoneal mass that, after biopsy, was diagnostic for a pancreatoblastoma. This mass was resected resulting in a fall in intraoperative PTH values and subsequent postoperative hypocalcemia secondary to hungry bone syndrome. Upon follow-up, the patient's parathyroid function recovered and doses of supplemental calcium and vitamin D could be tapered. Ectopic PTH-secreting masses represent a rare entity but should be considered in individuals with unclear etiology of recalcitrant primary hyperparathyroidism.

The effect of elevating extracellular CaCl2: Important considerations for tissue engineering applications

Polysaccharides such as sodium alginate, pectin and gellan gum are widely used biomaterials, for their ability to easily form hydrogels in the presence of divalent metal ions, such as calcium - a process often cited as a mild crosslinking mechanism. However, when using these materials as substrates for tissue engineering, there is a lack of extensive studies that investigate the impact of elevated calcium concentrations on cell health and behaviour. In this study, we performed an in-depth exploration to understand the potential effects of raising extracellular CaCl2 on cell viability, proliferation, morphology and migration. We used an established glioblastoma (GBM) cell line (U251), human dermal fibroblasts (HDF), and murine osteoblasts (MC3T3) to assess the consequences of using CaCl2 in tissue engineered models to help reevaluate biomaterial suitability and enhance standardisation practices in the field of tissue engineering. Our findings revealed that the addition of CaCl2 induced notable morphological changes in GBM cells when cultured in 3D hydrogels with excess CaCl2 added, leading to a transition from mesenchymal to amoeboid phenotypes, even at a concentration as low as 8 mM. Furthermore, cell viability was reduced in a concentration-dependent manner across all cell types, and migration was also affected. Despite the widespread use of high CaCl2 concentrations to facilitate scaffold gelation, our research unveils that there can be significant risks to cell viability, proliferation, morphology, and migration when such practices are not preceded by cell line-specific experimentation and thorough standardization procedures. This highlights the importance of careful consideration and optimisation of CaCl2 concentration when used as a crosslinking agent for hydrogels intended for use in tissue engineering applications that demand accurate recapitulation of cellular responses and physiological conditions.

De Novo Hypercalcaemia in a Patient With Chronic Hypoparathyroidism

Calcium Homeostasis in the human body is regulated by hormones, including parathyroid hormone and vitamin D3. Dysfunction in the form of hypoparathyroidism causes hypocalcaemia. In patients treated for primary hypoparathyroidism with activated vitamin D replacement, iatrogenic hypercalcaemia can occur. This must be investigated to exclude other aetiologies, such as malignancy and granulomatous disease. In this case report, we describe a 73-year-old man with a distant history of chronic hypoparathyroidism treated with vitamin D3 who presented with lethargy, confusion, polyuria, and polydipsia. On admission, he was found to be hypercalcaemic at 3.22 mmol/L. He presented on two previous occasions with symptomatic hypocalcaemia that resulted in a reduction and subsequent cessation of his vitamin D supplementation. This hypercalcaemia persisted, prompting investigations of non-iatrogenic causes. Computer tomography (CT) and positron emission tomography (PET) scans showed bilateral hilar lymphadenopathy and ruled out malignancy. Serum angiotensin-converting enzyme was three times the normal range while calcitriol levels were inappropriately raised, suggesting sarcoidosis as the likely aetiology of the hypercalcaemia. The patient was very responsive to steroid therapy, with serum calcium dropping to normal levels over a four-week admission. The patient developed hypocalcaemia within weeks of discharge, eventually requiring the recommencement of his vitamin D replacement, which has been titrated to maintain normal serum calcium levels. This case highlights a rare occurrence of two infiltrative disorders with simultaneous differential adverse effects on calcium metabolism, leading to a series of acute hospitalisations often alternating between severe hypocalcaemia or severe hypercalcaemia.

An emergency medicine review: Multiple myeloma and its complications

INTRODUCTION

Multiple myeloma (MM) and its complications carry a high rate of morbidity and mortality.

OBJECTIVE

This review evaluates MM and its complications, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

MM is the second most common hematologic cancer and associated with monoclonal plasma cell proliferation. The presentation of MM varies, ranging from few symptoms to end organ injury and failure. The most common presenting findings include anemia, bone pain, renal injury, fatigue, hypercalcemia, and weight loss. While clinical outcomes have improved with known therapies, a variety of complications may occur. Anemia is the most common hematologic complication, though hyperviscosity syndrome, bleeding, and coagulopathy may occur. Renal injury is common, and hypercalcemia is the result of bone demineralization. Infection is a major cause of morbidity and mortality. Osteolytic bone disease is a significant feature of MM, present in 70 % of patients, which may result in pathologic and insufficiency fractures. The most serious neurologic complication includes spinal cord compression, and other neurologic complications include peripheral neuropathy and intracranial involvement. Cardiac toxicity may occur with MM therapies, and there is also increased risk of venous thromboembolism. Endocrine complications may also occur, including adrenal insufficiency and thyroid dysfunction.

CONCLUSIONS

An understanding of the complications of MM can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Self-Assembly of Microstructured Protein Coatings with Programmable Functionality for Fluorescent Biosensors

Proteins, as genetically programmable functional macromolecules, hold immense potential as biocompatible self-assembling building blocks, owing to their versatility in building coating materials and programming their functionality genetically. In this study, we demonstrate a modular self-assembly of protein coatings that are genetically programmable for a biosensor application. We designed and produced recombinant fusion protein building blocks to form microstructured coatings on diverse substrates, such as glass or polymers, through thermally triggered liquid-liquid phase separation and an orthogonal high-affinity coiled-coil interaction. We incorporated fluorescence proteins into coatings and controlled the protein density to enable fluorescence imaging and quantification in a low-resource setting. Then, we created a coating for a calcium biosensor using a genetically engineered calcium indicator protein. This protein coating served as the foundation for our smartphone-based fluorescent biosensor, which successfully measured free calcium concentrations in the millimolar range at which extracellular calcium homeostasis is maintained. Using this fluorescent biosensor, we were able to detect abnormal physiological conditions, such as mild or moderate hypercalcemia. We envision that this modular and genetically programmable functional protein coating platform could be extended to the development of highly accessible, low-cost fluorescent biosensors for a variety of targets.

Pharmacologic or genetic interference with atrogene signaling protects against glucocorticoid-induced musculoskeletal and cardiac disease

Despite their beneficial actions as immunosuppressants, glucocorticoids (GC) have devastating effects on the musculoskeletal and cardiac systems, as long-term treated patients exhibit high incidence of falls, bone fractures, and cardiovascular events. Herein, we show that GC upregulate simultaneously in bone, skeletal muscle, and the heart the expression of E3 ubiquitin ligases (atrogenes), known to stimulate the proteasomal degradation of proteins. Activation of vitamin D receptor (VDR) signaling with the VDR ligands calcitriol or eldecalcitol prevented GC-induced atrogene upregulation in vivo and ex vivo in bone/muscle organ cultures and preserved tissue structure/mass and function of the 3 tissues in vivo. Direct pharmacologic inhibition of the proteasome with carfilzomib also conferred musculoskeletal protection. Genetic loss of the atrogene MuRF1-mediated protein ubiquitination in ΔRING mice afforded temporary or sustained protection from GC excess in bone or skeletal and heart muscle. We concluded that the atrogene pathway downstream of MuRF1 underlies GC action in bone, muscle, and the heart, and it can be pharmacologically or genetically targeted to confer protection against the damaging actions of GC simultaneously in the 3 tissues.

Atypically presented dysphagia in a patient with primary hyperparathyroidism that resolved after parathyroidectomy: A case report

INTRODUCTION

Dysphagia is a rare initial manifestation of primary hyperparathyroidism, which typically presents with gastrointestinal symptoms like anorexia and constipation. This case presentation aims to describe swallowing difficulty as a potential primary symptom of parathyroid hormone (PTH)-mediated hypercalcemia.

PRESENTATION OF CASE

An elderly Palestinian female presented with a two-year history of progressive dysphagia, along with mood disturbances and increased urination. Her medical history included osteoporosis and hyperparathyroidism. Laboratory tests showed elevated PTH and calcium levels. Imaging, including neck ultrasound (US) and Tc99m sestamibi scan, identified a parathyroid adenoma. Despite normal findings on esophagogastroduodenoscopy, a focused single parathyroidectomy was performed. Post-surgery, the patient's dysphagia resolved completely, and her calcium and PTH levels normalized.

DISCUSSION

This case highlights an atypical presentation of PTH-mediated hypercalcemia where dysphagia was the primary symptom. Literature review shows similar cases where parathyroid adenomas presented with unusual symptoms, emphasizing the need for thorough diagnostic evaluation. The resolution of dysphagia following surgery suggests a likely correlation between hypercalcemia and dysphagia, implying a possible causative association.

CONCLUSION

This case demonstrates dysphagia as a rare but significant symptom of hypercalcemia in a patient with a small parathyroid adenoma. Considering its size, it was unlikely to cause dysphagia through mechanical obstruction. Thus, a functional cause linked to hypercalcemia was likely to be the cause of dysphagia. Surgical removal of the adenoma resulted in resolution of symptoms. A literature review was performed, which revealed similar cases of dysphagia related to hypercalcemia, supporting the fact that in this patient, dysphagia was related to the hypercalcemia.

Rebound hypercalcemia after denosumab cessation during follow-up after surgical treatment for parathyroid carcinoma: case report and literature review

Denosumab is a potent antiresorptive medication, commonly used in the treatment of osteoporosis, as well as in a variety of other diseases. Potential adverse rebound effects after its cessation include a loss in bone mineral density and an increased risk of osteoporotic fractures. Hypercalcemia is a less frequently reported rebound phenomenon after denosumab discontinuation, that may pose a diagnostic challenge to physicians as a rare non-parathyroid hormone (PTH) dependent cause of hypercalcemia. In our case, a 47-year-old male presented with rebound hypercalcemia after denosumab cessation during follow-up after surgical treatment for parathyroid carcinoma. This non-PTH-dependent hypercalcemia resolved after re-initiation of denosumab. We performed a systematic literature review on rebound hypercalcemia after denosumab cessation and identified 52 individual patient cases. Children appear to be more prone to developing rebound hypercalcemia, which could be attributed to their higher baseline bone turnover, underlying conditions, or denosumab dosage regimens. In most cases, patients initially presented with acute and often severe symptoms of hypercalcemia that occur from 1.75 to 9 months after denosumab cessation (4 to 9 months in adults). Most effective treatment approaches to sufficiently decrease serum calcium levels were bisphosphonates or re-administration of denosumab. A watch and wait strategy may be sufficient in asymptomatic cases, which are less common and probably underdiagnosed. Subsequent antiresorptive treatment after denosumab cessation, which is a common practice in osteoporosis treatment, may reduce the risk of rebound hypercalcemia. As denosumab is a frequently used drug in patients with advanced malignant diseases and rebound hypercalcemia with low PTH levels may raise the suspicion for skeletal metastases, awareness of this rebound effect may be for particular relevance in such settings.

A Case of Primary Hyperparathyroidism With a Hypercalcemic Crisis Resulting in Distinct Bone Mineral Redistribution

Primary hyperparathyroidism (PHPT) is generally detected early, but this case involves a rare hypercalcemic crisis associated with a parathyroid adenoma. A 66-year-old man presented with extreme fatigue and loss of appetite. Serum calcium and parathyroid hormone (PTH) levels were elevated to 22.5 mg/dL and 3100 pg/mL, respectively. After the initial management of hypercalcemia, parathyroidectomy confirmed a benign adenoma. This case demonstrates a notable redistribution of bone minerals, with a significant decrease in cortical bone density but preservation, and even enhancement, of trabecular bone density. This redistribution highlights the complex dual action of PTH on bone metabolism, emphasizing the need for careful monitoring in severe PHPT cases.

Targeting Calcitriol Metabolism in Acute Vitamin D Toxicity-A Comprehensive Review and Clinical Insight

High-dose vitamin D supplementation is common in the general population, but unsupervised high-dose supplementation in vitamin D-replete individuals poses a risk of severe toxicity. Susceptibility to vitamin D toxicity shows a significant inter-individual variability that may in part be explained by genetic predispositions (i.e., CYP24A1 polymorphism). The classic manifestation of vitamin D toxicity is hypercalcemia, which may be refractory to conventional therapy. Its causes include the endogenous overaction of 1α-hydroxylase, monogenic alterations affecting vitamin D metabolizing enzymes and exogenous vitamin D intoxication. In this manuscript, we include a literature review of potential pharmacological interventions targeting calcitriol metabolism to treat vitamin D intoxication and present a case of severe, exogenous vitamin D intoxication responding to systemic corticosteroids after the failure of conventional therapy. Systemic glucocorticoids alleviate acute hypercalcemia by inhibiting enteric calcium absorption and increasing the degradation of vitamin D metabolites but may cause adverse effects. Inhibitors of 1α-hydroxylase (keto/fluconazole) and inducers of CYP3A4 (rifampicin) may be considered steroid-sparing alternatives for the treatment of vitamin D intoxication.

Calcium chloride poisoning: an autopsy case report and histologic features

Calcium chloride, which is commonly used in de-icing agents and desiccants, is known for the potential harm it can cause through skin contact, oral ingestion, or intravenous administration. The current paper reports on an autopsy case of a 68-year-old woman who died after ingesting an unknown substance. Histopathological examination revealed coagulative necrosis in the esophagus and ionized blood calcium levels that were significantly higher than normal. Calcium chloride was detected in the contents of the water bottle collected at the scene. These results are expected to make a significant contribution to the limited literature on fatal outcomes from calcium chloride ingestion, while emphasizing the need for heightened awareness and education about the risks of commonly available chemicals.

Challenging treatment of severe hypotension following tracheal intubation in a patient with primary hyperparathyroidism: A case report

RATIONALE

Primary hyperparathyroidism (PHPT), which is characterized by increased parathyroid hormone secretion, typically manifests as hypercalcemia and hypertension. Here, we report a case of severe hypotension following tracheal intubation during anesthesia induction in a patient with PHPT, in contrast to the expected hypertensive response.

PATIENT CONCERNS

A 52-year-old man presented with nausea after eating, leg pain when walking, and headaches.

DIAGNOSIS

Based on the blood test and computed tomography results, he was diagnosed with PHPT.

INTERVENTIONS

The patient underwent parathyroidectomy under general anesthesia. After induction anesthesia and tracheal intubation, severe acute hypotension and tachycardia suddenly developed. To treat hypotensive shock, we immediately administered ephedrine and phenylephrine and infused Ringer solution.

OUTCOMES

The symptoms of hypotensive shock were alleviated by this intervention.

LESSONS

We speculate that the cause of his severe hypotension was vasodilation due to the transient release of parathyroid hormone from mechanical stimulation by anesthetic procedures, such as tracheal intubation, combined with hypercalcemia-induced severe dehydration. Moreover, we speculate that fluid resuscitation stabilized his condition and helped achieve a successful surgical outcome. The possibility of severe hypotension after anesthesia induction should be anticipated, and management of cases with severe dehydration should be optimized during the anesthetic management of patients with PHPT.

Mixed glandular neuroendocrine carcinoma of the endometrium with hypercalcemic crisis

OBJECTIVE

To explore the ideas and research progress in diagnosing and treating hypercalcemic crisis in patients with cancer.

METHODS

We reviewed the clinical data, diagnosis and treatment of hypercalcemic crisis in a patient with mixed glandular neuroendocrine carcinoma of the endometrium.

RESULTS

The patient had gastrointestinal symptoms and acute renal impairment as the main manifestations, and the blood biochemical indexes suggested a hypercalcemic crisis with elevated parathyroid hormone (PTH). No lesions were seen in the parathyroid glands on imaging and nuclide imaging, but an abnormal pelvic mass was seen in the pelvis and the biopsy of the uterine cervix tissue suggested that it was an adenocarcinoma. Surgery was performed to remove the mass, and postoperative findings suggested endometrial large-cell neuroendocrine carcinoma with endometrioid adenocarcinoma. The calcium and PTH decreased to normal after surgery and chemotherapy.

CONCLUSIONS

The condition of the hypercalcemia crisis is dangerous, so it is necessary to think from different aspects of the clinical diagnosis and treatment.

Current advance of nanotechnology in diagnosis and treatment for malignant tumors

Cancer remains a significant risk to human health. Nanomedicine is a new multidisciplinary field that is garnering a lot of interest and investigation. Nanomedicine shows great potential for cancer diagnosis and treatment. Specifically engineered nanoparticles can be employed as contrast agents in cancer diagnostics to enable high sensitivity and high-resolution tumor detection by imaging examinations. Novel approaches for tumor labeling and detection are also made possible by the use of nanoprobes and nanobiosensors. The achievement of targeted medication delivery in cancer therapy can be accomplished through the rational design and manufacture of nanodrug carriers. Nanoparticles have the capability to effectively transport medications or gene fragments to tumor tissues via passive or active targeting processes, thus enhancing treatment outcomes while minimizing harm to healthy tissues. Simultaneously, nanoparticles can be employed in the context of radiation sensitization and photothermal therapy to enhance the therapeutic efficacy of malignant tumors. This review presents a literature overview and summary of how nanotechnology is used in the diagnosis and treatment of malignant tumors. According to oncological diseases originating from different systems of the body and combining the pathophysiological features of cancers at different sites, we review the most recent developments in nanotechnology applications. Finally, we briefly discuss the prospects and challenges of nanotechnology in cancer.

Differences in Vitamin A Levels and Their Association with the Atherogenic Index of Plasma and Subclinical Hypothyroidism in Adults: A Cross-Sectional Analysis in China

BACKGROUND

This study evaluates the association between vitamin A levels, AIP (the atherogenic index of plasma), and subclinical hypothyroidism.

METHODS

A cross-sectional analysis was conducted involving a representative sample of 3530 Chinese adults. Linear and logistic regression models were utilized to evaluate the associations between AIP and subclinical hypothyroidism, stratified by vitamin A levels. These analyses were further differentiated by sex and age groups to identify any demographic-specific associations.

RESULTS

In the vitamin A-sufficient group, an increase in AIP was associated with elevated total triiodothyronine (TT3) levels (β = 0.26, 95%CI: 0.09, 0.41, p = 0.003). Conversely, in the group with severe vitamin A deficiency, higher AIP levels were linked to increased free triiodothyronine (fT3) and TT3 levels and decreased free thyroxine (fT4) levels (β = 0.12, 0.03, and -0.29, respectively). Additionally, severe vitamin A deficiency increased the risk associated with AIP and subclinical hypothyroidism (OR = 1.66, 95%CI: 1.07, 2.58, p = 0.025). This risk was notably more pronounced in women and older adults, with odds ratios of 2.44 (95%CI: 1.55, 3.86, p < 0.001) and 2.14 (95%CI: 1.36, 3.38, p = 0.001), respectively.

CONCLUSIONS

Vitamin A deficiency may increase the risk of the association between AIP and subclinical hypothyroidism, particularly among women and the elderly.

Sporadic Parathyroid Carcinoma Treated With Lenvatinib, Exhibiting a Novel Somatic MEN1 Mutation

Parathyroid carcinoma (PC) is extremely rare and is primarily treated surgically. Chemotherapy is an option for advanced stages, but no standard regimen exists. Emerging research suggests the efficacy of multitarget tyrosine kinase inhibitors (MTKIs) for PC, targeting vascular endothelial growth factor receptor (VEGFR) and platelet-derived growth factor receptor (PDGFR). A 61-year-old Japanese woman presented with a neck mass, diagnosed as PC with pleural and lumbar metastases. After parathyroidectomy and radiation for lumbar metastasis, immunohistochemistry showed VEGFR overexpression, leading to targeted therapy with MTKIs. Despite no actionable mutations on cancer genomic panel test, a novel MEN1 somatic mutation (NM_130801: exon2: c.332delG: p.G111fs*8) was identified, which may affect VEGFR2 expression and tumor epigenetics. Although severe hand-foot syndrome necessitated dose reductions and treatment interruptions, sorafenib treatment managed hypercalcemia with evocalcet and denosumab. Lenvatinib, as second-line therapy, was effective against pleural metastases but caused thrombocytopenia and hematuria, leading to discontinuation and uncontrolled recurrence and metastasis progression. Our case highlights the need for further research on genomic profiling, molecular targets, and therapy response in PC.

Hypercalcemia as a rare manifestation of immune reconstitution inflammatory syndrome (IRIS) in a person living with Human Immunodeficiency Virus (HIV) with disseminated nontuberculous mycobacteriosis

INTRODUCTION

Granulomatosis due to immune reconstitution inflammatory syndrome (IRIS) and disseminated Mycobacterium avium-intracellulare (M. avium) infection may trigger hypercalcemia. Here, we report a rare case of hypercalcemia and acute kidney damage related to IRIS in a person living with Human Immunodeficiency Virus (HIV).

CASE PRESENTATION

A 39-year-old male person living with HIV presented with muscle weakness and unwanted weight loss of 8 kg within the last 2 weeks. Laboratory findings included serum hypercalcemia of 3.27 mmol/mL associated with elevated calcitriol and acute kidney damage. Since the first diagnosis of HIV and concomitant disseminated M. avium infection, the patient received antiretroviral therapy (ART), rifabutin, clarithromycin, and ethambutol. 18Fluoro-D-glucose positron emission computed tomography (18FDG-PET/CT) showed progressive multilocular lymphadenopathy. Biopsy specimen from the duodenum as well as retroperitoneal and mediastinal lymph nodes revealed granulomatous inflammation consistent with IRIS. Treatment with forced diuresis, bisphosphonates, and calcitonin normalized serum calcium and kidney function recovered.

CONCLUSION

Hypercalcemia due to IRIS is a rare differential diagnosis in persons living with HIV and may lead to acute kidney damage, despite sufficient ART and antimycobacterial treatment.

Clinical and epidemiologic characteristics of hospitalized oncological patients with hypercalcemia: a longitudinal, multicenter study

BACKGROUND

There are few studies that have analyzed the characteristics of hypercalcemia in hospitalized oncological patients. Our objectives were to describe the clinical characteristics of hospitalized patients with paraneoplastic hypercalcemia and to identify prognostic variables for mortality.

METHODS

This was an observational, longitudinal, retrospective, and bicentric study. It included adult patients admitted to two hospitals in Málaga, Spain (2014-2018). The minimum follow-up period was 2 years or until death.

RESULTS

A total of 154 patients were included; the majority (71.4%) were admitted to the internal medicine department. The median follow-up was 3.5 weeks (interquartile range [IQR] 1.1-11.5). The mean (standard deviation) age was 67.6 (12.3) years, with a predominance of males (58.4%). The median (IQR) serum calcium at admission was 13.2 (11.8-14.6) mg/dl. The most common neoplasms were pulmonary (27.3%), hematologic (23.4%), urological (13%), and breast (12.3%). Furthermore, 56.5% of cases had a known history of neoplasia at the time of diagnosis. The parathyroid hormone (PTH) level was determined in 24%; of these, 10.8% had elevated levels. In all, 95.5% of patients died during follow-up. The median survival was 3.4 weeks (95% confidence interval 2.6-4.3). Factors associated with higher mortality were age, serum calcium at admission, previous history of neoplasia, etiology other than multiple myeloma, and noncorrection of hypercalcemia.

CONCLUSIONS

In hospitalized patients, paraneoplastic hypercalcemia was associated with high short-term mortality. Several factors associated with a worse prognosis were identified in these patients.

Intentional vomiting as a rare cause of hypercalcemia and consequent acute renal failure: a case report

Two most common causes of elevated serum calcium levels, which together account for nearly 90% of all cases, are primary hyperparathyroidism and malignancy. Thus, it is necessary to consider other disorders in the diagnostic evaluation of patients with hypercalcemia. We report the case of a 40-year-old female patient with an intellectual disability who was admitted to the Emergency Department with severe symptomatic hypercalcemia and acute renal failure, caused by recurrent intentional vomiting. The aim of this report is to help clinicians make an accurate diagnosis by considering recurrent vomiting habits as a potential cause of hypercalcemia and acute renal failure. Our case provides a comprehensive diagnostic work-up and multidisciplinary treatment strategies for patients with symptomatic hypercalcemia.

Safety and Efficacy of Denosumab in Children With Osteogenesis Imperfecta-the First Prospective Comparative Study

CONTEXT

Denosumab is a potential therapeutic agent for osteogenesis imperfecta (OI), but its efficacy and safety remain unclear in children with OI.

OBJECTIVE

We aimed to investigate the effects of denosumab on bone mineral density (BMD), spinal morphometry, and safety in children with OI compared with zoledronic acid.

METHODS

In this prospective study, 84 children or adolescents with OI were randomized to receive denosumab subcutaneous injection every 6 months or zoledronic acid intravenous infusion once. Changes of BMD and its Z-score, vertebral shape, serum levels of calcium and bone turnover biomarkers were assessed during the 1-year treatment.

RESULTS

After 12 months of treatment, BMD at the lumbar spine, femoral neck, and total hip significantly increased by 29.3%, 27.8%, and 30.2% in the denosumab group, and by 32.2%, 47.1%, and 41.1% in the zoledronic acid group (all P < .001 vs baseline). Vertebral height and projection area significantly increased after denosumab and zoledronic acid treatment. Rebound hypercalcemia was found to be a common and serious side effect of denosumab, of which 14.3% reached hypercalcemic crisis. Rebound hypercalcemia could be alleviated by switching to zoledronic acid treatment.

CONCLUSION

Treatment with denosumab or zoledronic acid is beneficial in increasing BMD and improving the spinal morphometry of children with OI. However, denosumab should be used with caution in pediatric patients with OI because of its common and dangerous side effect of rebound hypercalcemia. The appropriate dosage and dosing interval of denosumab need to be further explored in children with OI.

Random Occurrence or Real Association? Primary Hyperparathyroidism in a Young Man With Sickle Cell Disease

A 32-year-old man with sickle cell disease (SCD) was admitted to the hospital for sickle cell crisis, during which laboratory workup revealed primary hyperparathyroidism. His treatment regimen included hydration, calcitonin, and calcimimetics. A parathyroid nuclear scan revealed anomalous parathyroid tissue. The precise relationship between primary hyperparathyroidism (PHPT) and SCD remains incompletely understood but may involve factors such as vitamin D deficiency, elevated erythropoietin levels, and the influence of growth factors on the development of parathyroid adenomas. Furthermore, the concurrent occurrence of both PHPT and SCD at an earlier age may potentiate adverse long-term outcomes. Effective management of PHPT in SCD entails addressing hypercalcemia and treating the underlying cause of hyperparathyroidism. While a potential association between PHPT and SCD exists, further research is essential to better elucidate their interaction, prevalence, clinical presentations, and outcomes.

Coincidence or Causality: Parathyroid Carcinoma in Chronic Kidney Disease-Case Report and Literature Review

Parathyroid carcinoma (PC) associated with primary hyperparathyroidism (PHPT) has been well investigated in recent years. Data regarding PC evolution in secondary hyperparathyroidism (SHPT) due to chronic kidney disease (CKD) are, however, scarce. Most features that raise the suspicion of PC in PHPT are part of the usual SHPT evolution in CKD, mirroring the natural changes undergone by the parathyroid glands. Therefore, pre-surgically establishing the malignant or benign character of the lesions is cumbersome. We present two cases of PC in end-stage renal disease, one of which was bilateral, diagnosed after total parathyroidectomy in a high-volume parathyroid surgery center. A literature review of the data was also performed. A systematic search of the PubMed/MEDLINE database until January 2024 identified 42 cases of PC associated with SHPT. Understanding the PC features in CKD might improve associated bone and mineral disease management, and reduce the risk of metastasis, parathyromatosis, or recurrence. Irradiation, prolonged immunosuppression, long dialysis vintage, and genotype may predispose to the malignant transformation of chronically stimulated parathyroids. Despite postsurgical diagnosis, favorable outcomes occurred when distant metastases were absent, even without "en bloc" resection. Further research is warranted to delineate specific diagnostic and therapeutic approaches tailored to this particular patient subpopulation.

Intersecting Paths: Unraveling the Complex Journey of Cancer to Bone Metastasis

The phenomenon of bone metastases presents a significant challenge within the context of advanced cancer treatments, particularly pertaining to breast, prostate, and lung cancers. These metastatic occurrences stem from the dissemination of cancerous cells into the bone, thereby interrupting the equilibrium between osteoblasts and osteoclasts. Such disruption results in skeletal complications, adversely affecting patient morbidity and quality of life. This review discusses the intricate interplay between cancer cells and the bone microenvironment, positing the bone not merely as a passive recipient of metastatic cells but as an active contributor to cancer progression through its distinctive biochemical and cellular makeup. A thorough examination of bone structure and the dynamics of bone remodeling is undertaken, elucidating how metastatic cancer cells exploit these processes. This review explores the genetic and molecular pathways that underpin the onset and development of bone metastases. Particular emphasis is placed on the roles of cytokines and growth factors in facilitating osteoclastogenesis and influencing osteoblast activity. Additionally, this paper offers a meticulous critique of current diagnostic methodologies, ranging from conventional radiography to advanced molecular imaging techniques, and discusses the implications of a nuanced understanding of bone metastasis biology for therapeutic intervention. This includes the development of targeted therapies and strategies for managing bone pain and other skeletal-related events. Moreover, this review underscores the imperative of ongoing research efforts aimed at identifying novel therapeutic targets and refining management approaches for bone metastases. It advocates for a multidisciplinary strategy that integrates advancements in medical oncology and radiology with insights derived from molecular biology and genetics, to enhance prognostic outcomes and the quality of life for patients afflicted by this debilitating condition. In summary, bone metastases constitute a complex issue that demands a comprehensive and informed approach to treatment. This article contributes to the ongoing discourse by consolidating existing knowledge and identifying avenues for future investigation, with the overarching objective of ameliorating patient care in the domain of oncology.

Mycobacterium avium paratuberculosis Infection Suppresses Vitamin D Activation and Cathelicidin Production in Macrophages through Modulation of the TLR2-Dependent p38/MAPK-CYP27B1-VDR-CAMP Axis

BACKGROUND

Vitamin D plays a vital role in modulating both innate and adaptive immune systems. Therefore, vitamin D deficiency has been associated with higher levels of autoimmune response and increased susceptibility to infections. CYP27B1 encodes a member of the cytochrome P450 superfamily of enzymes. It is instrumental in the conversion of circulating vitamin D (calcifediol) to active vitamin D (calcitriol). This is a crucial step for macrophages to express Cathelicidin Anti-microbial Peptide (CAMP), an anti-bacterial factor released during the immune response. Our recent study indicated that a Crohn's disease (CD)-associated pathogen known as Mycobacterium avium paratuberculosis (MAP) decreases vitamin D activation in macrophages, thereby impeding cathelicidin production and MAP infection clearance. The mechanism by which MAP infection exerts these effects on the vitamin D metabolic axis remains elusive.

METHODS

We used two cell culture models of THP-1 macrophages and Caco-2 monolayers to establish the effects of MAP infection on the vitamin D metabolic axis. We also tested the effects of Calcifediol, Calcitriol, and SB203580 treatments on the relative expression of the vitamin D metabolic genes, oxidative stress biomarkers, and inflammatory cytokines profile.

RESULTS

In this study, we found that MAP infection interferes with vitamin D activation inside THP-1 macrophages by reducing levels of CYP27B1 and vitamin D receptor (VDR) gene expression via interaction with the TLR2-dependent p38/MAPK pathway. MAP infection exerts its effects in a time-dependent manner, with the maximal inhibition observed at 24 h post-infection. We also demonstrated the necessity to have toll-like receptor 2 (TLR2) for MAP infection to influence CYP27B1 and CAMP expression, as TLR2 gene knockdown resulted in an average increase of 7.78 ± 0.88 and 13.90 ± 3.5 folds in their expression, respectively. MAP infection also clearly decreased the levels of p38 phosphorylation and showed dependency on the p38/MAPK pathway to influence the expression of CYP27B1, VDR, and CAMP which was evident by the average fold increase of 1.93 ± 0.28, 1.86 ± 0.27, and 6.34 ± 0.51 in their expression, respectively, following p38 antagonism. Finally, we showed that calcitriol treatment and p38/MAPK blockade reduce cellular oxidative stress and inflammatory markers in Caco-2 monolayers following macrophage-mediated MAP infection.

CONCLUSIONS

This study characterized the primary mechanism by which MAP infection leads to diminished levels of active vitamin D and cathelicidin in CD patients, which may explain the exacerbated vitamin D deficiency state in these cases.

Diagnostic Value of Imaging and Serological Biomarkers in Pulmonary Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of an unknown aetiology. It can exist in many organs. Pulmonary and intrathoracic lymph nodes are most commonly involved. Lung sarcoidosis is uncommon in Asia. However, due to the large population of our country and the development of bronchoscopy, percutaneous lung puncture, and other medical technologies, the number of pulmonary sarcoidosis patients is on the rise. Pulmonary sarcoidosis patients have no obvious symptoms in the early stage, and the clinical manifestations in the later stage may vary from person to person. Eventually, the disease progresses to life-threatening pulmonary fibrosis. Therefore, patients with pulmonary sarcoidosis should receive a timely diagnosis. In recent years, the imaging features and serologic biomarkers of pulmonary sarcoidosis have been continuously studied. The diagnostic value of imaging and serologic biomarkers for pulmonary sarcoidosis is summarized below.

Patient-reported outcome measures for primary hyperparathyroidism: a systematic review of measurement properties

BACKGROUND

The quality of patient-reported outcome measures (PROMs) used to assess the outcomes of primary hyperparathyroidism (PHPT), a common endocrine disorder that can negatively affect patients' health-related quality of life due to chronic symptoms, has not been rigorously examined. This systematic review aimed to summarize and evaluate evidence on the measurement properties of PROMs used in adult patients with PHPT, and to provide recommendations for appropriate measure selection.

METHODS

After PROSPERO registration (CRD42023438287), Medline, EMBASE, CINAHL Complete, Web of Science, PsycINFO, and Cochrane Trials were searched for full-text articles in English investigating PROM development, pilot studies, or evaluation of at least one PROM measurement property in adult patients with any clinical form of PHPT. Two reviewers independently identified studies for inclusion and conducted the review following the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) Methodology to assess risk of bias, evaluate the quality of measurement properties, and grade the certainty of evidence.

RESULTS

From 4989 records, nine PROM development or validation studies were identified for three PROMs: the SF-36, PAS, and PHPQoL. Though the PAS demonstrated sufficient test-retest reliability and convergent validity, and the PHPQoL sufficient test-retest reliability, convergent validity, and responsiveness, the certainty of evidence was low-to-very low due to risk of bias. All three PROMs lacked sufficient evidence for content validity in patients with PHPT.

CONCLUSIONS

Based upon the available evidence, the SF-36, PAS, and PHPQoL cannot currently be recommended for use in research or clinical care, raising important questions about the conclusions of studies using these PROMs. Further validation studies or the development of more relevant PROMs with strong measurement properties for this patient population are needed.

Hypercalcemic Crisis Complicated With Acute Respiratory Distress Syndrome Due to Hot Spring Drowning: A Case Report

Hypercalcemia is generally treated conservatively, including massive fluid administration. However, in cases of acute respiratory distress syndrome (ARDS) associated with drowning, excessive fluid administration may worsen respiratory status. An 81-year-old female was found drowned in a hot spring at an accommodation facility and urgently transported to our hospital. On arrival, the patient exhibited severe respiratory failure, impaired consciousness, and bilateral lung infiltrates on computed tomography (CT), suggesting ARDS. Blood biochemical tests showed calcium (Ca) of 17.4 mg/dL, with altered consciousness attributed to hypercalcemia. Because of concerns about further deterioration of respiratory status, hemodialysis was performed to avoid massive fluid administration. Post-hemodialysis, blood calcium levels quickly decreased, leading to improved consciousness and respiration; the patient was extubated 48 hours post-admission. Subsequent examinations identified hot spring water aspiration as the cause of hypercalcemia. For hypercalcemia from hot spring drowning with acute respiratory distress syndrome, consider early hemodialysis initiation without excessive fluid administration.

Clinical and outcome comparison of genetically positive vs. negative patients in a large cohort of suspected familial hypocalciuric hypercalcemia

OBJECTIVE

Biochemical suspicion of familial hypocalciuric hypercalcemia (FHH) might provide with a negative (FHH-negative) or positive (FHH-positive) genetic result. Understanding the differences between both groups may refine the identification of those with a positive genetic evaluation, aid management decisions and prospective surveillance. We aimed to compare FHH-positive and FHH-negative patients, and to identify predictive variables for FHH-positive cases.

DESIGN

Retrospective, national multi-centre study of patients with suspected FHH and genetic testing of the CASR, AP2S1 and GNA11 genes.

METHODS

Clinical, biochemical, radiological and treatment data were collected. We established a prediction model for the identification of FHH-positive cases by logistic regression analysis and area under the ROC curve (AUROC) was estimated.

RESULTS

We included 66 index cases, of which 30 (45.5%) had a pathogenic variant. FHH-positive cases were younger (p = 0.029), reported more frequently a positive family history (p < 0.001), presented higher magnesium (p < 0.001) and lower parathormone levels (p < 0.001) and were less often treated for hypercalcemia (p = 0.017) in comparison to FHH-negative cases. Magnesium levels showed the highest AUROC (0.825, 95%CI: 0.709-0.941). The multivariate analysis revealed that family history and magnesium levels were independent predictors of a positive genetic result. The predictive model showed an AUROC of 0.909 (95%CI: 0.826-0.991).

CONCLUSIONS

The combination of magnesium and a positive family history offered a good diagnostic accuracy to predict a positive genetic result. Therefore, the inclusion of magnesium measurement in the routine evaluation of patients with suspected FHH might provide insight into the identification of a positive genetic result of any of the CaSR-related genes.

Calcium Chaos in Sarcoidosis: A Tale of Severe Hypercalcemia's Diagnostic Challenge

Sarcoidosis is a systemic inflammatory condition characterized by noncaseating granulomas. Lung involvement is typical, while extrapulmonary manifestations, notably lymphadenopathy, are observed in a significant proportion of cases. The etiology involves complex interactions among immune cells and mediators, resulting in granuloma formation capable of independently producing 1,25-dihydroxyvitamin D, leading to unregulated hypercalcemia and hypercalciuria. Diagnosis can be challenging, especially when hypercalcemia is the initial symptom. The presence of noncaseating granulomas on biopsy is characteristic of sarcoidosis. We present a case of severe hypercalcemia in a 53-year-old woman, initially suggestive of primary hyperparathyroidism due to non-suppressed intact parathyroid hormone (PTH) levels and unilateral intrathyroidal tracer uptake on a technetium 99m sestamibi parathyroid scan. The patient presented with hypertension, acute kidney injury, and severe hypercalcemia. Initial assessment, including a parathyroid scan, hinted at primary hyperparathyroidism. However, further evaluation, including chest computed tomography (CT) and endobronchial biopsy, revealed sarcoidosis with noncaseating granulomas. Prednisone therapy led to normalization of serum calcium and creatinine levels. The case underscores the complexities in diagnosing sarcoidosis, especially when presenting with severe hypercalcemia. Despite non-suppressed PTH and suggestive imaging, the final diagnosis relied on endobronchial biopsy findings. The study highlights the limitations of conventional diagnostic markers, emphasizing the need for a comprehensive and individualized approach.

Case report: Death caused by multi-organ metastatic calcifications as a result of intramuscular injections with paraffin oil

In this forensic case report, we present autopsy findings from a young male in his thirties who had been self-injecting paraffin oil into his upper extremities 8 years prior to death. The injections induced an inflammatory response, leading to granuloma formation. This, in turn, resulted in severe hypercalcemia. The external autopsy examination revealed gross macroscopic ulcerations and enlargement of upper extremities, while calcifications of ligaments, heart, kidneys and dura mater was revealed on postmortem CT-scans. Histopathological examination showed extensive multiorgan metastatic calcifications in several tissues including the lungs, heart and kidney. Cause of death was estimated to be the extensive calcific deposits in the heart likely resulting in cardiac arrest. To our knowledge this is the first case reporting findings from an autopsy in which the cause of death was linked to cosmetic oil injections.

Can Patients with Electrolyte Disturbances Be Safely and Effectively Treated in a Hospital-at-Home, Telemedicine-Controlled Environment? A Retrospective Analysis of 267 Patients

BACKGROUND

Morbidities indicated for hospital-at-home (HAH) treatment include infectious diseases and exacerbations of chronic conditions. Electrolyte disturbances are not included per se. However, their rate is high. We aimed to describe our experience via the monitoring and treatment of such patients.

METHODS

This was a retrospective analysis of patients in the setting of telemedicine-controlled HAH treatment. We collected data from the electronic medical records of patients who presented electrolyte disturbances.

RESULTS

For 14 months, we treated 267 patients in total in HAH settings, with a mean age of 72.2 + 16.4, 44.2% for males. In total, 261 (97.75%) patients were flagged with electrolyte disturbances, of whom 149 had true electrolyte disturbances. Furthermore, 67 cases (44.96%) had hyponatremia, 9 (6.04%) had hypernatremia after correction for hyperglycemia, 20 (13.42%) had hypokalemia and 27 (18.12%) had hyperkalemia after the exclusion of hemolytic samples. Ten (6.09%) patients had hypocalcemia and two (1.34%) had hypercalcemia corrected to albumin levels. Thirteen (8.72%) patients had hypomagnesemia and one (0.67%) had hypermagnesemia. Patients with electrolyte disturbances suffered from more chronic kidney disease (24.2% vs. 12.2%; p = 0.03) and malignancy (6.3% vs. 0.6%; p = 0.006), and were more often treated with diuretics (12.6% vs. 4.1%; p = 0.016). No patient died or suffered from clinically significant cardiac arrhythmias.

CONCLUSIONS

The extent of electrolyte disturbances amongst HAH treatment patients is high. The monitoring and treatment of such patients can be conducted safely in this setting.

Bridging the Gap in Understanding Bone Metastasis: A Multifaceted Perspective

The treatment of patients with advanced cancer poses clinical problems due to the complications that arise as the disease progresses. Bone metastases are a common problem that cancer patients may face, and currently, there are no effective drugs to treat these individuals. Prostate, breast, and lung cancers often spread to the bone, causing significant and disabling health conditions. The bone is a highly active and dynamic tissue and is considered a favorable environment for the growth of cancer. The role of osteoblasts and osteoclasts in the process of bone remodeling and the way in which their interactions change during the progression of metastasis is critical to understanding the pathophysiology of this disease. These interactions create a self-perpetuating loop that stimulates the growth of metastatic cells in the bone. The metabolic reprogramming of both cancer cells and cells in the bone microenvironment has serious implications for the development and progression of metastasis. Insight into the process of bone remodeling and the systemic elements that regulate this process, as well as the cellular changes that occur during the progression of bone metastases, is critical to the discovery of a cure for this disease. It is crucial to explore different therapeutic options that focus specifically on malignancy in the bone microenvironment in order to effectively treat this disease. This review will focus on the bone remodeling process and the effects of metabolic disorders as well as systemic factors like hormones and cytokines on the development of bone metastases. We will also examine the various therapeutic alternatives available today and the upcoming advances in novel treatments.

Calcium supplementation for the prevention of hypertension: a synthesis of existing evidence and implications for practise

Hypertension (also known as high blood pressure), is a medical condition characterized as a persistently raised blood pressure of the pulmonary artery. Effective interventions to treat hypertension typically involve two approaches: lifestyle modifications and pharmacotherapy. One specific lifestyle intervention which aims to increase calcium uptake through dietary supplementation, has recently gained popularity because of its potential to be low-cost and population based. Research suggests that this intervention may be effective given that calcium has been found to have an inverse relationship with blood pressure and hypertension. That said, studies have shown that there may be potential risks to patient health through adverse events such as kidney stone formation and increased cardiovascular events. Association between calcium supplementation and adverse events could have an impact on population health and prevent widespread adoption of the intervention. Because of the need to establish the effectiveness of this intervention assessed against any possible harms, it is now necessary to review the current evidence and evaluate its implications for clinical practise.

[Hyper- and hypocalcemia: what should you watch out for?]

Calcium is essential for numerous metabolic processes and is hormonally controlled. These hormonal mechanisms are surprisingly effective in regulating calcium levels very reliably within a narrow range - but deviations in serum calcium levels quite often cause clinical problems. Hypercalcemia predominantly occurs in primary hyperparathyroidism or is associated with tumors (especially osteolytic processes). Hypocalcemia is usually due to hypoparathyroidism (75% surgical, 25% primary) or vitamin D deficiency. Causal calcium management requires identification of the etiology of the disorder. Symptomatic therapy depends on the severity of the electrolyte imbalance. Calcium is lowered in hypercalcemia via forced diuresis, the administration of calcitonin and bisphosphonates or denosumab, if necessary, via dialysis. Severe hypocalcemia is corrected acutely with parenteral calcium administration and any further treatment decisions and prognosis depend on the underlying disease.

Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement

Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.

Incidental Diagnosis of Williams Syndrome in an Adult With Recurrent Hypercalcemia

Williams syndrome (WS) is a rare genetic disorder with multisystem involvement associated with hypercalcemia. The cause of this hypercalcemia is poorly understood and while primarily associated with WS children, it is also observed in adults. A 51-year-old woman with intellectual disability, renal insufficiency, recurrent pancreatitis, and intermittent hypercalcemia despite partial parathyroidectomy presented with hypercalcemia to 14 mg/dL (3.49 mmol/L; normal 8.6-10.5 mg/dL [2.12-2.62 mmol/L]) at routine follow-up. Laboratory testing was notable for acute-on-chronic renal failure with unremarkable vitamin D, urine calcium, and parathyroid hormone. She presented to the emergency department and was admitted. Treatment with bisphosphonates, calcitonin, and intravenous fluids decreased calcium to 9.4 mg/dL (2.35 mmol/L) and improved kidney function. She was discharged with recommendations for increased oral hydration, a low-calcium diet, and outpatient follow-up. Her phenotype was suspicious for WS, later confirmed with genetic testing. This case exemplifies both the increased risk of hypercalcemia in WS adults and the need to consider WS in hypercalcemic adults with intellectual disability. It also serves to illustrate the importance of recognizing WS features in potentially undiagnosed adults and reviews guidelines for hypercalcemia surveillance and management in WS adults.

Factors influencing serum calcium levels and the incidence of hypocalcemia after parathyroidectomy in primary hyperparathyroidism patients

Background

Parathyroidectomy (PTX) is an effective treatment for primary hyperparathyroidism (PHPT) patients. Postoperative hypocalcemia is a common complication after PTX. This study aimed to analyze the factors influencing serum calcium levels and the incidence of hypocalcemia after parathyroidectomy in primary hyperparathyroidism patients.

Methods

The retrospective study included 270 PHPT patients treated with PTX and collected their demographic and clinical information and their laboratory indices. Factors influencing serum calcium levels and hypocalcemia after PTX in PHPT patients were analyzed using univariate and multifactorial analyses.

Results

First, in patients with normal preoperative serum calcium levels (2.20-2.74 mmol/L), the higher the preoperative alkaline phosphatase and serum phosphorus levels, the lower the postoperative serum calcium levels. Furthermore, the higher the preoperative serum calcium levels and the accompanying clinical symptoms, the higher the postoperative serum calcium levels. Low preoperative serum calcium levels were shown to be a risk factor for postoperative hypocalcemia (OR=0.022), and the optimal preoperative serum calcium threshold was 2.625 mmol/L (sensitivity and specificity were 0.587 and 0.712, respectively). Second, in the mild preoperative hypercalcemia group (2.75-3.00 mmol/L), the older the patient, the higher the preoperative and postoperative serum calcium levels, the higher the postoperative serum calcium; the lower the alkaline phosphatase and calcitonin levels, the higher the postoperative serum calcium levels. On the other hand, the younger the patient was, the more likely hypocalcemia blood was (OR=0.947), with an optimal age threshold of 47.5 years (sensitivity and specificity were 0.543 and 0.754, respectively). Third, in the preoperative moderate to severe hypercalcemia group (>3.0mmol/L), patients undergoing a combined contralateral thyroidectomy and a total thyroidectomy had low postoperative serum calcium levels.

Conclusion

Patients with different preoperative serum calcium levels had various factors influencing their postoperative serum calcium levels and postoperative hypocalcemia, which facilitated the assessment of their prognosis.

P7C3 Ameliorates Bone Loss by Inhibiting Osteoclast Differentiation and Promoting Osteogenesis

Bone homeostasis, the equilibrium between bone resorption and formation, is essential for maintaining healthy bone tissue in adult humans. Disruptions of this process can lead to pathological conditions such as osteoporosis. Dual-targeted agents, capable of inhibiting excessive bone resorption and stimulating bone formation, are being explored as a promising strategy for developing new treatments to address osteoporosis. In this study, we investigated the effects of P7C3 on bone remodeling and its potential therapeutic role in osteoporosis treatment in mice. Specifically, P7C3 can remarkably suppress receptor activator of nuclear factor-κB (NF-κB) ligand (RANKL)-induced osteoclast differentiation in bone marrow macrophages via the Akt-NF-κB-NFATc1 signaling pathway. Additionally, RNA sequencing (RNAseq) analysis revealed that P7C3 promoted osteoblast differentiation and function through the Wnt/β-catenin signaling pathway, thereby enhancing bone formation. Furthermore, μCT analysis and histological examination of bone tissues from P7C3-treated mice showed attenuation of both Ti-induced bone erosion and ovariectomy (OVX)-induced bone loss. These findings suggest that P7C3 may have a novel function in bone remodeling and may be a promising therapeutic agent for the treatment of osteoporosis. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Frequency and determinants of serum calcium monitoring during eldecalcitol therapy in patients with osteoporosis

INTRODUCTION

Eldecalcitol (ELD) is an active vitamin D3 analog (AVD) commonly used to treat osteoporosis in Japan. Although routine monitoring of serum calcium levels during ELD therapy is recommended, little is known about the actual frequency and determinants of monitoring.

MATERIALS AND METHODS

This was a descriptive cohort study using a Japanese electronic medical records database. We identified osteoporosis patients who initiated treatment with ELD or other AVDs (alfacalcidol and calcitriol) between April 1, 2011 and September 10, 2021. The index date for cohort entry was the first prescription date of ELD or other AVDs. The frequency of serum calcium monitoring was evaluated every 6 months. Determinants of serum calcium monitoring were identified using multivariable logistic regression models. We also calculated the incidence of hypercalcemia and the frequency of serum calcium monitoring within 6 months before hypercalcemia.

RESULTS

We identified 12,671 ELD users and 7867 other AVD users. Within 6 months after cohort entry, 45.9% of ELD users and 58.7% of other AVD users underwent serum calcium monitoring. Female sex, no use of systemic corticosteroids, moderate-to-good renal function, treatment in smaller hospitals, and treatment in orthopedic surgery departments were associated with a lower likelihood of receiving serum calcium monitoring during ELD therapy. The incidence of hypercalcemia among ELD users was 6.36 per 100 person-years, with 20.6% of cases not receiving serum calcium monitoring before hypercalcemia.

CONCLUSION

Our findings suggest that serum calcium monitoring is not given adequate attention during ELD therapy in routine clinical practice.

Malignant hypercalcemia revealing a diffuse large B-cell lymphoma in a patient with a previous diagnosis of chronic myelomonocytic leukemia: An uncommon hematological coexistence

A 76-year-old patient previously admitted to the cardiology department for replacement of a right ventricular lead on a double-chamber pacemaker was admitted to the internal medicine department 15 days after for bronchopneumopathy. His past medical history was relevant for Type 2 diabetes mellitus, heart failure due to dilated hypokinetic heart disease, transcatheter aortic valve implantation (TAVI), and chronic myelomonocytic leukemia (CMML-0) diagnosed in 2021. Twenty-four hours after admission, the patient's general condition deteriorated abruptly, with the onset of drowsiness and psychomotor retardation. Laboratory exams revealed hypercalcemia at 4.18 mmol/L. Intensive hydration, calcitonin, and zoledronic acid were initiated and the patient was transferred to the nephrology intensive care unit where he underwent two sessions of hemodialysis to normalize serum calcium levels before readmission to internal medicine. Laboratory exams revealed low parathyroid hormone, normal 1-25-OH vitamin D, and increased parathyroid hormone-related peptide. Thoracoabdominal and positron emission tomography (PET) scan showed diffuse abdominopelvic peritoneal carcinosis associated with low-grade pleural effusion and multiple supra- and sub-diaphragmatic adenopathies, leading to a search for a solid tumor. The patient's clinical condition worsened leading to a transfer to the intensive care unit. The biopsy of a peritoneal carcinosis nodule confirmed the diagnosis of diffuse large B-cell lymphoma. Specific treatments were unsuccessful and the patient expired.