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Opoku I, Atemnkeng N, Vila N. A Case of Milk-Alkali Syndrome. Cureus 2023; 15:e38171. [PMID: 37252584 PMCID: PMC10224712 DOI: 10.7759/cureus.38171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Milk-alkali syndrome is described by a triad of elevated levels of calcium, metabolic alkalosis, and acute kidney injury that historically occurred as a result of the combined intake of large amounts of calcium and absorbable alkali. It is becoming common recently with the use of over-the-counter calcium supplements for osteoporosis treatment in postmenopausal women. We present a case of a 62-year-old female who presented with generalized weakness. She was noted to have severe hypercalcemia, and impaired renal function with a significant history of daily over-the-counter calcium supplement use and as-needed calcium carbonate use for gastroesophageal reflux disease (GERD). This case highlights the stepwise approach to the evaluation and management of hypercalcemia. She was appropriately treated with the resolution of hypercalcemia and presenting symptoms.
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Affiliation(s)
- Isaac Opoku
- Internal Medicine, Piedmont Athens Regional, Athens, USA
| | | | - Nedsely Vila
- Internal Medicine, Piedmont Athens Regional, Athens, USA
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2
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Abstract
IMPORTANCE Hypercalcemia affects approximately 1% of the worldwide population. Mild hypercalcemia, defined as total calcium of less than 12 mg/dL (<3 mmol/L) or ionized calcium of 5.6 to 8.0 mg/dL (1.4-2 mmol/L), is usually asymptomatic but may be associated with constitutional symptoms such as fatigue and constipation in approximately 20% of people. Hypercalcemia that is severe, defined as total calcium of 14 mg/dL or greater (>3.5 mmol/L) or ionized calcium of 10 mg/dL or greater (≥2.5 mmol/L) or that develops rapidly over days to weeks, can cause nausea, vomiting, dehydration, confusion, somnolence, and coma. OBSERVATIONS Approximately 90% of people with hypercalcemia have primary hyperparathyroidism (PHPT) or malignancy. Additional causes of hypercalcemia include granulomatous disease such as sarcoidosis, endocrinopathies such as thyroid disease, immobilization, genetic disorders, and medications such as thiazide diuretics and supplements such as calcium, vitamin D, or vitamin A. Hypercalcemia has been associated with sodium-glucose cotransporter 2 protein inhibitors, immune checkpoint inhibitors, denosumab discontinuation, SARS-CoV-2, ketogenic diets, and extreme exercise, but these account for less than 1% of causes. Serum intact parathyroid hormone (PTH), the most important initial test to evaluate hypercalcemia, distinguishes PTH-dependent from PTH-independent causes. In a patient with hypercalcemia, an elevated or normal PTH concentration is consistent with PHPT, while a suppressed PTH level (<20 pg/mL depending on assay) indicates another cause. Mild hypercalcemia usually does not need acute intervention. If due to PHPT, parathyroidectomy may be considered depending on age, serum calcium level, and kidney or skeletal involvement. In patients older than 50 years with serum calcium levels less than 1 mg above the upper normal limit and no evidence of skeletal or kidney disease, observation may be appropriate. Initial therapy of symptomatic or severe hypercalcemia consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate. In patients with kidney failure, denosumab and dialysis may be indicated. Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas). Treatment reduces serum calcium and improves symptoms, at least transiently. The underlying cause of hypercalcemia should be identified and treated. The prognosis for asymptomatic PHPT is excellent with either medical or surgical management. Hypercalcemia of malignancy is associated with poor survival. CONCLUSIONS AND RELEVANCE Mild hypercalcemia is typically asymptomatic, while severe hypercalcemia is associated with nausea, vomiting, dehydration, confusion, somnolence, and coma. Asymptomatic hypercalcemia due to primary hyperparathyroidism is managed with parathyroidectomy or observation with monitoring, while severe hypercalcemia is typically treated with hydration and intravenous bisphosphonates.
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Affiliation(s)
- Marcella Donovan Walker
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, Vagelos College of Physicians and Surgeons, New York, New York
| | - Elizabeth Shane
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, Vagelos College of Physicians and Surgeons, New York, New York
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Bondje S, Barnes C, Kaplan F. Another case of milk–alkali syndrome or a learning opportunity? Endocrinol Diabetes Metab Case Rep 2022. [PMCID: PMC9175614 DOI: 10.1530/edm-21-0151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Summary Milk–alkali syndrome (MAS) is a triad of hypercalcaemia, metabolic alkalosis and renal insufficiency. In this study, we present a case of milk–alkali syndrome secondary to concurrent use of over-the-counter (OTC) calcium carbonate-containing antacid tablets (Rennie®) for dyspepsia and calcium carbonate with vitamin D3 (Adcal D3) for osteoporosis. A 72-year-old woman presented with a 2-day history of nausea, vomiting, epigastric pain, constipation, lethargy and mild delirium. Past medical history included osteoporosis treated with daily Adcal D3. Initial blood tests showed elevated serum-adjusted calcium of 3.77 mmol/L (normal range, 2.2–2.6) and creatinine of 292 µmol/L (45–84) from a baseline of 84. This was corrected with i.v. pamidronate and i.v. fluids. She developed asymptomatic hypocalcaemia and rebound hyperparathyroidism. Myeloma screen, vasculitis screen and serum angiotensin-converting enzyme (ACE) were normal, while the CT of the chest, abdomen and pelvis showed renal stones but no malignancy. A bone marrow biopsy showed no evidence of malignancy. Once the delirium resolved, we established that prior to admission, she had been excessively self-medicating with over-the-counter antacids (Rennie®) as required for epigastric pain. The increasing use of calcium preparations for the management of osteoporosis in addition to easily available OTC dyspepsia preparations has made MAS the third most common cause of hypercalcaemia hospitalisations. Educating patients and healthcare professionals on the risks associated with these seemingly safe medications is required. Appropriate warning labels on both calcium preparations used in the management of osteoporosis and OTC calcium-containing preparations would prevent further similar cases and unnecessary morbidity and hospital admission. Learning points
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Hypercalcemia, Acute Kidney Injury, and Metabolic Alkalosis. Case Rep Nephrol 2022; 2022:1320259. [PMID: 35433065 PMCID: PMC9007678 DOI: 10.1155/2022/1320259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 12/02/2022] Open
Abstract
Calcium regulation is tightly controlled in the body. Multiple causes of hypercalcemia have been studied including primary hyperparathyroidism, hypercalcemia of malignancy, and chronic granulomatous disorders. Among the less studied causes is calcium-alkali syndrome. Here, we discuss a case of hypercalcemia secondary to calcium-alkali syndrome, presenting with hypercalcemia, metabolic alkalosis, and acute kidney injury as a result of ingestion of a large amount of calcium supplements. Hypercalcemia can result in impaired collecting duct system sensitivity to antidiuretic hormone, afferent arteriole constriction, and activation of calcium sensor receptors in multiple tissues. The net effect is an increase in calcium reabsorption with a salt and water diuresis which leads to volume depletion, acute kidney injury, and metabolic alkalosis.
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Abstract
Extracellular calcium is normally tightly regulated by parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, as well as by calcium ion (Ca++) itself. Dysregulated PTH production leading to hypercalcemia occurs most commonly in sporadic primary hyperparathryoidism (PHPT) but may also result from select genetic mutations in familial disorders. Parathyroid hormone-related protein shares molecular mechanisms of action with PTH and is the most common cause of hypercalcemia of malignancy. Other cytokines and mediators may also cause resorptive hypercalcemia once bone metastases have occurred. Less commonly, extrarenal production of calcitriol can occur in malignancies and in infectious and noninfectious inflammatory conditions and can cause hypercalcemia.
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Affiliation(s)
- David Goltzman
- Calcium Research Laboratory, Department of Medicine and Physiology, McGill University, Research Institute of the McGill University Health Centre, Glen Site, 1001 Decarie Boulevard, Room EM1.3220, Montreal, Quebec H4A 3J1, Canada.
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6
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Zayed RF, Millhouse PW, Kamyab F, Ortiz JF, Atoot A. Calcium-Alkali Syndrome: Historical Review, Pathophysiology and Post-Modern Update. Cureus 2021; 13:e13291. [PMID: 33732556 PMCID: PMC7955894 DOI: 10.7759/cureus.13291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Milk-alkali syndrome or calcium-alkali syndrome (CAS) is the triad of hypercalcemia, metabolic alkalosis and renal impairment. It is often related to ingestion of high amounts of calcium carbonate, which was used historically for the treatment of peptic ulcer disease. The incidence of the syndrome decreased dramatically after the introduction of newer peptic ulcer medications such as proton pump inhibitors and histamine blocking agents. However, a resurgence was seen in the late 1980s with the wide use of over-the-counter calcium supplements, mainly by females for osteoporosis prophylaxis. The modern version of the syndrome continues to evolve along with medical management. This review focuses on the historical context of CAS, pathogenesis, resurgence of the condition with variable presentations, and contemporary management.
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Affiliation(s)
- Randa F Zayed
- Internal Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, USA
| | - Paul W Millhouse
- General Practice, Drexel University College of Medicine, Philadelphia, USA
| | - Farnaz Kamyab
- Architecture, Arts and Humanities, Clemson University, Clemson, USA
| | - Juan Fernando Ortiz
- Neurology, Universidad San Francisco de Quito, Quito, ECU.,Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Adam Atoot
- Internal Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, USA
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Cimpeanu E, Mammadova A, Valdes Bracamontes J, Otterbeck P. Antacid-induced acute hypercalcemia: An increasingly common and potentially dangerous occurrence. SAGE Open Med Case Rep 2020; 8:2050313X20921335. [PMID: 32489665 PMCID: PMC7238301 DOI: 10.1177/2050313x20921335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 03/27/2020] [Indexed: 11/29/2022] Open
Abstract
Hypercalcemia is frequently encountered in both hospital wards and the primary
care setting; 90% of cases can be attributed to primary hyperparathyroidism and
malignancy. However, a minority are caused by medications, of which calcium
supplements have been an increasingly common etiology. We are presenting a case
of hypercalcemia resulted after acute oral intake of a moderate amount of
antacids (calcium tablets) and normalized after supplement withdrawal.
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Affiliation(s)
- Emanuela Cimpeanu
- Department of Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Aytan Mammadova
- Department of Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Philip Otterbeck
- Department of Endocrinology, Richmond University Medical Center, Staten Island, NY, USA
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Vu K, Becker G, Eagerton D. A 39 year-old woman with milk-alkali syndrome complicated by posterior reversible encephalopathy syndrome. Bone Rep 2020; 12:100278. [PMID: 32455151 PMCID: PMC7235952 DOI: 10.1016/j.bonr.2020.100278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/22/2020] [Accepted: 05/01/2020] [Indexed: 11/30/2022] Open
Abstract
Milk-alkali syndrome (MAS) is characterized by the triad of hypercalcemia, metabolic alkalosis, and acute kidney injury. Once thought to be a rare condition, there has been a resurgence of cases due to the consumption of calcium-containing supplements for osteoporosis prevention and dyspepsia in the general population. We describe the case of a female who presented with acute encephalopathy, hypercalcemia, and new-onset seizure. An extensive hypercalcemia workup and ruling out of other causes led to the diagnosis of MAS from excessive intake of calcium carbonate. Brain magnetic resonance imaging revealed signal abnormalities in the occipital and posterior parietal lobes that were indicative of posterior reversible encephalopathy syndrome. The patient's encephalopathy resolved after treatment of her hypercalcemia with fluid resuscitation and cessation of her calcium supplements. We present our case to highlight this unusual presentation of MAS, challenges in diagnosis, and briefly discuss the pathophysiology underlying hypercalcemia-induced encephalopathy.
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Parvataneni S, Essrani R, Mehershahi S, Essrani R, Lohana AK, Mehmood A. Over-the-Counter Drug Causing Acute Pancreatitis. J Investig Med High Impact Case Rep 2020; 8:2324709620922724. [PMID: 32434384 PMCID: PMC7243389 DOI: 10.1177/2324709620922724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute pancreatitis is caused by alcohol, gall stone disease, drugs, trauma, infections, and metabolic causes such as hypercalcemia and hyperlipidemia. Hypercalcemia-induced acute pancreatitis has been well documented but only rarely occurs due to over-the-counter calcium carbonate. In this article, we present a case of over-the-counter calcium carbonate–induced acute pancreatitis.
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Affiliation(s)
- Swetha Parvataneni
- Geisinger Lewistown Hospital, Lewistown, PA, USA
- Swetha Parvataneni, MD, Internal Medicine, Geisinger Lewistown Hospital, 400 Highland Avenue, Lewistown, PA 17044-1198, USA.
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Bhadra R, Khan FA, Soliman M, Somasundaram M, Iltchev DV, Ravakhah K. Rare complication of milk-alkali ingestion: severe pancreatitis and acute kidney injury in a chronic hypocalcaemic patient with DiGeorge's syndrome. BMJ Case Rep 2019; 12:12/3/e226761. [PMID: 30878954 DOI: 10.1136/bcr-2018-226761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Injudicious use of over-the-counter calcium supplements has resulted in increased incidences of hypercalcaemia and related complications. We present a case of acute pancreatitis in a chronic hypocalcaemic patient of DiGeorge's syndrome. The patient came into the ED with sepsis syndrome, right upper quadrant and epigastric pain and no obvious source of infection. Lab results and imaging were indicative of acute pancreatitis. There was severe renal dysfunction. The patient needed haemodialysis and had a prolonged stay in intensive care. The medical history was negative for biliary duct pathology or alcohol use. The patient had vomiting and diarrhoea in the nursing home for about a week, but she continued to receive her regular medications that included the calcium supplements and thiazide diuretics. It is likely that a complex interplay between calcium supplementation, dehydration and thiazide diuretics resulted in the development of acute pancreatitis and severe renal dysfunction in a chronic hypocalcaemic patient.
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Affiliation(s)
- Rajarshi Bhadra
- Department of Internal Medicine, St Vincent Charity Medical Center, Cleveland, Ohio, USA
| | - Fareeha Ahmed Khan
- Department of Internal Medicine, St Vincent Charity Medical Center, Cleveland, Ohio, USA
| | - Mona Soliman
- Department of Internal Medicine, St Vincent Charity Medical Center, Cleveland, Ohio, USA
| | - Meyappan Somasundaram
- Department of Internal Medicine, St Vincent Charity Medical Center, Cleveland, Ohio, USA
| | - Daniel V Iltchev
- Department of Pulmonary and Critical Care Medicine, St Vincent Charity Medical Center, Cleveland, Ohio, USA
| | - Keyvan Ravakhah
- Department of Internal Medicine, St Vincent Charity Medical Center, Cleveland, Ohio, USA
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Aloia JF, Katumuluwa S, Stolberg A, Usera G, Mikhail M, Hoofnagle AN, Islam S. Safety of calcium and vitamin D supplements, a randomized controlled trial. Clin Endocrinol (Oxf) 2018; 89:742-749. [PMID: 30180273 DOI: 10.1111/cen.13848] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE It is anticipated that an intake of vitamin D found acceptable by Endocrine Society Guidelines (10 000 IU/day) with co-administered calcium supplements may result in frequent hypercalciuria and hypercalcaemia. This combination may be associated with kidney stones. The objective of this study was to compare the episodes of hypercalciuria and hypercalcaemia from calcium supplements co-administered with 10 000 IU or 600 IU vitamin D daily. This design allows a comparison of the Institute of Medicine recommendation for the RDA of vitamin D along with the upper limit of calcium intake with the high intake of vitamin D suggested by the Endocrine Society. CONTEXT Harms of currently recommended high intake of vitamin D have not been studied. DESIGN The design was a randomized controlled trial with 2 groups with evaluation every 3 months for one year: (a) CaCO3 1200 mg/day with 10 000 IU vitamin D3 /day or (b) CaCO3 1200 mg/day with 600 IU vitamin D3 /day. PATIENTS This study was conducted in an ambulatory research centre in healthy, white postmenopausal women. MEASUREMENTS Serum and 24-hour urine calcium were measured. RESULTS Hypercalcaemia and hypercalciuria occurred in both groups. At the final visit, 19/48 in the high dose D group had hypercalciuria. The odds of developing hypercalciuria were 3.6 [OR = 3.6(1.39, 9.3)] times higher in the high dose D group. The odds of developing hypercalcaemia did not differ between groups. CONCLUSIONS The safe upper level of vitamin D recommended by the Endocrine Society when accompanied by calcium supplements results in frequent hypercalciuria. The risk of kidney stones at these levels should be investigated.
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Affiliation(s)
- John F Aloia
- Winthrop University Hospital, Bone Mineral Research Center, Mineola, New York
| | | | - Alexandra Stolberg
- Winthrop University Hospital, Bone Mineral Research Center, Mineola, New York
| | - Gianina Usera
- Winthrop University Hospital, Bone Mineral Research Center, Mineola, New York
| | - Mageda Mikhail
- Winthrop University Hospital, Bone Mineral Research Center, Mineola, New York
| | | | - Shahidul Islam
- Winthrop University Hospital, Bone Mineral Research Center, Mineola, New York
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Trezevant MS, Winton JC, Holmes AK. Hypercalcemia-Induced Pancreatitis in Pregnancy Following Calcium Carbonate Ingestion. J Pharm Pract 2017; 32:225-227. [PMID: 29241388 DOI: 10.1177/0897190017745410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Calcium carbonate is often used to relieve Gastroesophageal Reflux Disease (GERD) in pregnant patients. This report describes a potentially serious complication. CASE A pregnant female presented at 34 weeks gestation with abdominal pain, nausea, and vomiting. Home medications included an unquantifiable amount of calcium carbonate 500 mg due to constant consumption for GERD. Laboratory findings included elevated calcium, amylase, lipase, and triglyceride level. Pancreatitis was diagnosed and abdominal ultrasound excluded gallstones. Despite hydration, lipase rose and emergency cesarean section was performed. Hypercalcemia was managed by intravenous fluid administration. After delivery, pancreatitis resolved. CONCLUSION Pancreatitis developed in pregnant patient with hypercalcemia due to excessive calcium carbonate ingestion and resolved after delivery of the fetus, fluid resuscitation, and return of calcium level to normal.
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Affiliation(s)
- May S Trezevant
- 1 Pharmacy Department, Methodist Le Bonheur Healthcare, Germantown, TN, USA
- 2 Department of Pharmacy Practice, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - John C Winton
- 3 Greenville Health System - Hospitalist Division, Greenville Memorial Hospital, Greenville, SC, USA
| | - Ashley K Holmes
- 4 Pharmacy Department, Saint Luke's Hospital, Kansas City, MO, USA
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Stoney B, Bagchi G. Antacid abuse: a rare cause of severe hypercalcaemia. BMJ Case Rep 2017; 2017:bcr-2017-219611. [DOI: 10.1136/bcr-2017-219611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Brunel V, Wils J, Thuillez C. Chronically Hypocalcemic Patient with Hypercalcemia. Clin Chem 2016; 62:783-4. [DOI: 10.1373/clinchem.2015.247023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/11/2015] [Indexed: 11/06/2022]
Affiliation(s)
| | - Julien Wils
- Department of Pharmacology, Rouen University Hospital, Rouen, France
| | - Christian Thuillez
- Department of Medical Biochemistry, and
- Department of Pharmacology, Rouen University Hospital, Rouen, France
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15
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Stojceva-Taneva O, Taneva B, Selim G. Hypercalcemia as a Cause of Kidney Failure: Case Report. Open Access Maced J Med Sci 2016; 4:283-6. [PMID: 27335601 PMCID: PMC4908746 DOI: 10.3889/oamjms.2016.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/06/2016] [Accepted: 03/14/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND: Hypercalcemia is a common manifestation in clinical practice and occurs as a result of primary hyperparathyroidism, malignancy, milk-alkali syndrome, hyper or hypothyroidism, sarcoidosis and other known and unknown causes. Patients with milk-alkali syndrome typically are presented with renal failure, hypercalcemia, and metabolic alkalosis caused by the ingestion of calcium and absorbable alkali. This syndrome is caused by high intake of milk and sodium bicarbonate. CASE PRESENTATION: We present a 28-year old male admitted to hospital with a one-month history of nausea, vomiting, epigastric pain, increased blood pressure and worsening of renal function with hypercalcemia. His serum PTH level was almost undetectable; he had mild alkalosis, renal failure with eGFR of 42 ml/min, anemia, hypertension and abnormal ECG with shortened QT interval and ST elevation in V1-V4. He had a positive medical history for calcium-containing antacids intake and after ruling out primary hyperparathyroidism, malignancy, multiple myelomas, sarcoidosis, and thyroid dysfunction, it seemed plausible to diagnose him as having the milk-alkali syndrome. CONCLUSION: Although milk-alkali syndrome currently may be more probably a result of calcium and vitamin D intake in postmenopausal women, or in elderly men with reduced kidney function taking calcium-containing medications, one should not exclude the possibility of its appearance in younger patients taking calcium-containing medications and consider it a serious condition taking into account its possibility of inducing renal insufficiency.
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Affiliation(s)
- Olivera Stojceva-Taneva
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Borjanka Taneva
- University Clinic of Cardiology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Gjulsen Selim
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Klingeman HM, Kearns AE. 69-Year-Old Woman With Confusion and Fatigue. Mayo Clin Proc 2016; 91:e1-6. [PMID: 26763520 DOI: 10.1016/j.mayocp.2015.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/16/2015] [Accepted: 06/25/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Heather M Klingeman
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Ann E Kearns
- Advisor to resident and Consultant in Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.
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Lee IH, Noh SY, Kang GW. Milk-alkali syndrome secondary to the intake of calcium supplements. Yeungnam Univ J Med 2016. [DOI: 10.12701/yujm.2016.33.1.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- In Hee Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Sin Young Noh
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Gun Woo Kang
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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18
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Sendos LN, Mian IM, Shah NL. Betel Nut Chewing: An Unrecognized Cause of Milk Alkali Syndrome. AACE Clin Case Rep 2016. [DOI: 10.4158/ep13413.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Handford CE, Campbell K, Elliott CT. Impacts of Milk Fraud on Food Safety and Nutrition with Special Emphasis on Developing Countries. Compr Rev Food Sci Food Saf 2015; 15:130-142. [DOI: 10.1111/1541-4337.12181] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/29/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Caroline E. Handford
- the Inst. for Global Food Security, School of Biological Sciences; Queen's Univ. Belfast; 18-30 Malone Rd. Belfast Northern Ireland BT9 5BN United Kingdom
| | - Katrina Campbell
- the Inst. for Global Food Security, School of Biological Sciences; Queen's Univ. Belfast; 18-30 Malone Rd. Belfast Northern Ireland BT9 5BN United Kingdom
| | - Christopher T. Elliott
- the Inst. for Global Food Security, School of Biological Sciences; Queen's Univ. Belfast; 18-30 Malone Rd. Belfast Northern Ireland BT9 5BN United Kingdom
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Incidence of hypercalciuria and hypercalcemia during vitamin D and calcium supplementation in older women. Menopause 2015; 21:1173-80. [PMID: 24937025 DOI: 10.1097/gme.0000000000000270] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to prospectively assess the incidence of hypercalciuria and hypercalcemia with different doses of vitamin D and with a calcium intake of approximately 1,200 mg/day. METHODS This was a 1-year randomized placebo-controlled study of vitamin D (400-4,800 IU/d) in 163 white women aged 57 to 90 years. Calcium citrate tablets (200 mg) were added to the diet to achieve a total calcium intake of approximately 1,200 mg/day in all groups. All women had vitamin D insufficiency at baseline, with serum 25-hydroxyvitaminD levels lower than 20 ng/mL (50 nmol/L). Serum and 24-hour urine calcium were collected every 3 months on supplementation, any test result above the upper reference range represented an episode of hypercalcemia or hypercalciuria. Mixed-effects models and multivariate logistic regression were used in the analysis. RESULTS Hypercalcemia (>10.2 mg/dL [2.55 mmol/L]) occurred in 8.8% of white women. Hypercalciuria (>300 mg/d [7.5 mmol]) occurred in 30.6% of white women. Episodes of hypercalciuria were transient in half of the group and recurrent in the other half. No relationship between hypercalcemia or hypercalciuria and vitamin D dose was found, and hypercalciuria was equally common in the placebo group. CONCLUSIONS Hypercalciuria and hypercalcemia commonly occur with vitamin D and calcium supplements. Whether hypercalciuria and hypercalcemia are caused by calcium, vitamin D, or both is unclear. These findings may have relevance to the reported increase in kidney stones in the Women's Health Initiative trial. Because calcium 1,200 mg and vitamin D 800 IU/day are widely recommended in postmenopausal women, systematic evaluation of the safety of supplements is warranted in clinical management and in future studies.
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Singh A, Ashraf A. Hypercalcemic crisis induced by calcium carbonate. Clin Kidney J 2015; 5:288-91. [PMID: 25874082 PMCID: PMC4393470 DOI: 10.1093/ckj/sfs060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 04/23/2012] [Indexed: 12/23/2022] Open
Abstract
We report a rare case of drug-induced hypercalcemic crisis in an elderly male resulting from calcium-containing supplements facilitated by thiazide diuretic and angiotensin-converting enzyme inhibitor. A 61-year-old male presented with hypercalcemic crisis along with renal insufficiency and metabolic alkalosis, mimicking the ‘calcium-alkali syndrome’. The patient responded to aggressive intravenous hydration along with emergent hemodialysis and salmon calcitonin. He did not have hyperparathyroidism or malignancy. History revealed an average daily intake of only 1200 mg of calcium carbonate along with vitamin D 1000 U/day over an extended period of time. The patient completely recovered in 3 days and had normal serum calcium, parathyroid hormone and phosphorous level at 3-month follow-up. The case highlights the life-threatening perils of indiscriminate and often excessive intake of calcium-containing supplements in an appropriate clinical setting. We also briefly discuss the epidemiology, clinical and laboratory features along with the recent advances in the understanding of the pathophysiology of calcium-alkali syndrome.
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Affiliation(s)
| | - Ambika Ashraf
- Division of Pediatric Endocrinology , University of Alabama , Birmingham, AL , USA
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Machado MC, Bruce-Mensah A, Whitmire M, Rizvi AA. Hypercalcemia Associated with Calcium Supplement Use: Prevalence and Characteristics in Hospitalized Patients. J Clin Med 2015; 4:414-24. [PMID: 26239247 PMCID: PMC4470136 DOI: 10.3390/jcm4030414] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The ingestion of large amounts of milk and antacids to treat peptic ulcer disease was a common cause of hypercalcemia in the past (the "milk-alkali syndrome"). The current popularity of calcium and supplements has given rise to a similar problem. OBJECTIVES To evaluate the prevalence and characteristics of hypercalcemia induced by calcium intake ("calcium supplement syndrome"; or CSS) in hospitalized patients. METHODS We conducted a retrospective; electronic health record (EHR)-based review of patients with hypercalcemia over a 3-year period. Diagnosis of CSS was based on the presence of hypercalcemia; a normal parathyroid hormone (PTH) level; renal insufficiency; metabolic alkalosis; a history of calcium intake; and documented improvement with treatment. RESULTS Of the 72 patients with non-PTH mediated hypercalcemia; 15 (20.8%) satisfied all the criteria for the diagnosis of CSS. Calcium; vitamin D; and multivitamin ingestion were significantly associated with the diagnosis (p values < 0.0001; 0.014; and 0.045 respectively); while the presence of hypertension; diabetes; and renal insufficiency showed a trend towards statistical significance. All patients received intravenous fluids; and six (40%) received calcium-lowering drugs. The calcium level at discharge was normal 12 (80%) of patients. The mean serum creatinine and bicarbonate levels decreased from 2.4 and 35 mg/dL on admission respectively; to 1.6 mg/dL and 25.6 mg/dL at discharge respectively. CONCLUSION The widespread use of calcium and vitamin D supplementation can manifest as hypercalcemia and worsening of kidney function in susceptible individuals. Awareness among health care professionals can lead to proper patient education regarding these health risks.
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Affiliation(s)
- Maria C Machado
- Division of Endocrinology, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
| | - Araba Bruce-Mensah
- University of South Carolina School of Medicine, Columbia, SC 29203, USA.
| | - Melanie Whitmire
- Research Unit, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
| | - Ali A Rizvi
- Division of Endocrinology, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
- Department of Medicine, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
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Daniel NJ, Wadman MC, Branecki CE. Milk-alkali-induced pancreatitis in a chronically hypocalcemic patient with DiGeorge syndrome. J Emerg Med 2014; 48:e63-6. [PMID: 25498850 DOI: 10.1016/j.jemermed.2014.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pancreatitis is a common diagnosis in the emergency department (ED), and milk-alkali syndrome (MAS) is an uncommon etiology for pancreatitis. MAS is caused by increased calcium and alkali ingestion, causing hypercalcemia accompanied by metabolic alkalosis and renal failure. Once considered rare, MAS is an increasingly common cause of hypercalcemia. Awareness of the resurgence of this syndrome is important for emergency physicians when recalling the causes of renal failure and pancreatitis. We present a case of pancreatitis and acute renal failure (ARF) in a chronically hypocalcemic DiGeorge syndrome patient, resulting from hypercalcemia secondary to excessive ingestion of calcium carbonate tablets. CASE REPORT A patient with DiGeorge syndrome and chronic abdominal pain due to gastroesophageal reflux disease (GERD) presented to our ED for severe abdominal pain. He reported nausea and vomiting, as well as epigastric pain that seemed worse than his typical pain. Laboratory evaluation revealed pancreatitis and ARF, although the patient had no prior history of these conditions. Upon further questioning, his mother divulged that the patient had been taking large quantities of calcium carbonate tablets for his worsening GERD symptoms. The patient was admitted to the intensive care unit where his pancreatitis and ARF eventually resolved as his calcium levels returned to his baseline. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MAS is a relatively uncommon diagnosis, but can lead to serious sequelae such as pancreatitis and ARF. Questioning the patient about calcium ingestion is an important facet to the diagnosis and work-up of pancreatitis and ARF. Recognition of this etiology can improve patient outcomes and prevent recurrences.
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Affiliation(s)
- Nicholas J Daniel
- Department of Emergency Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
| | - Michael C Wadman
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Chad E Branecki
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE
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Abstract
The majority of clinical complaints derive from disorders of calcium metabolism and are associated with a wide variety of clinical symptoms caused by numerous diseases with entirely different types of pathophysiology. The prognosis varies from favorable to fatal depending on the pathophysiology of the underlying disorder of calcium metabolism; therefore, the diagnostic work-up aims to quickly identify the underlying disease causing the disturbance in calcium homeostasis. Every clinical situation with a diminished state of calcium absorption is treated with calcium and vitamin D in varying doses whereas every disorder with an increased calcium absorptive or resorptive state is treated with improved diuresis in addition to antiresorptive drugs, such as bisphosphonates. In many situations the management of a disturbed calcium balance requires an interdisciplinary approach in order to treat the underlying disease in parallel with correction of the calcium homeostasis.
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Hypervitaminosis A Causing Hypercalcemia in Cystic Fibrosis. Case Report and Focused Review. Ann Am Thorac Soc 2014; 11:1244-7. [DOI: 10.1513/annalsats.201404-170bc] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Monereo Muñoz M, Lalondriz Bueno Y, Martínez Riera A, Santolaria F. Síndrome de leche y alcalinos asociado a anorexia nerviosa. Rev Clin Esp 2014; 214:53-4. [DOI: 10.1016/j.rce.2013.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 10/28/2013] [Indexed: 11/29/2022]
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Patel AM, Adeseun GA, Goldfarb S. Calcium-alkali syndrome in the modern era. Nutrients 2013; 5:4880-93. [PMID: 24288027 PMCID: PMC3875933 DOI: 10.3390/nu5124880] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/31/2013] [Accepted: 11/14/2013] [Indexed: 12/23/2022] Open
Abstract
The ingestion of calcium, along with alkali, results in a well-described triad of hypercalcemia, metabolic alkalosis, and renal insufficiency. Over time, the epidemiology and root cause of the syndrome have shifted, such that the disorder, originally called the milk-alkali syndrome, is now better described as the calcium-alkali syndrome. The calcium-alkali syndrome is an important cause of morbidity that may be on the rise, an unintended consequence of shifts in calcium and vitamin D intake in segments of the population. We review the pathophysiology of the calcium-alkali syndrome.
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Affiliation(s)
- Ami M. Patel
- Division of Nephrology and Hypertension, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Gbemisola A. Adeseun
- Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; E-Mail:
| | - Stanley Goldfarb
- Division of Renal-Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; E-Mail:
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Maier JD, Levine SN. Hypercalcemia in the Intensive Care Unit: A Review of Pathophysiology, Diagnosis, and Modern Therapy. J Intensive Care Med 2013; 30:235-52. [PMID: 24130250 DOI: 10.1177/0885066613507530] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/13/2013] [Indexed: 02/02/2023]
Abstract
Hypercalcemia may be seen in a variety of clinical settings and often requires intensive management when serum calcium levels are dramatically elevated. All of the many etiologies of mild hypercalcemia can lead to severe hypercalcemia. Knowledge of the physiologic mechanisms involved in maintaining normocalcemia and basic pathophysiology is essential for making a timely diagnosis and hence prompt institution of etiology-specific therapy. The development of new medications and critical reviews of traditional therapies have changed the treatment paradigm for severe hypercalcemia, calling for a more limited role for aggressive isotonic fluid administration and furosemide and an expanded role for calcitonin and the bisphosphonates. Experimental therapies such as denosumab show promise.
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Affiliation(s)
- Joshua D Maier
- Department of Medicine, Section of Endocrinology and Metabolism, Overton Brooks Veterans Administration Medical Center, Shreveport, LA, USA
| | - Steven N Levine
- Department of Medicine, Section of Endocrinology and Metabolism, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Borkenhagen JF, Connor EL, Stafstrom CE. Neonatal hypocalcemic seizures due to excessive maternal calcium ingestion. Pediatr Neurol 2013; 48:469-71. [PMID: 23668874 DOI: 10.1016/j.pediatrneurol.2013.02.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 02/14/2013] [Accepted: 02/15/2013] [Indexed: 10/26/2022]
Abstract
Hypocalcemia is a common, treatable cause of neonatal seizures. A term girl neonate with no apparent risk factors developed seizures on day 5 of life, consisting of rhythmic twitching of all extremities in a migrating pattern. Physical examination was normal except for jitteriness. Laboratory evaluation was unremarkable except for decreased total and ionized serum calcium levels and an elevated serum phosphorus level. The mother had ingested 3-6 g of calcium carbonate daily during the final 4 months of pregnancy to control morning sickness. The baby's electroencephalogram showed multifocal interictal sharp waves and intermittent electrographic seizures consisting of focal spikes in the left hemisphere accompanied by rhythmic jerking of the right arm and leg. Treatment with intravenous calcium gluconate over several days resulted in cessation of seizures and normalization of serum calcium. The child has remained seizure free and is normal developmentally at 9 years of age. Hypocalcemic seizures in this newborn were likely secondary to excessive maternal calcium ingestion, which led to transient neonatal hypoparathyroidism and hypocalcemia. Inquiry about perinatal maternal medication use should include a search for over-the-counter agents that might not be thought of as "drugs," as in this case, antacids.
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Affiliation(s)
- Jenna F Borkenhagen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53705, USA
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Abstract
The milk-alkali syndrome was a common cause of hypercalcemia, metabolic alkalosis, and renal failure in the early 20th century. It was caused by the ingestion of large quantities of milk and absorbable alkali to treat peptic ulcer disease. The syndrome virtually vanished after introduction of histamine-2 blockers and proton pump inhibitors. More recently, a similar condition called the calcium-alkali syndrome has emerged as a common cause of hypercalcemia and alkalosis. It is usually caused by the ingestion of large amounts of calcium carbonate salts to prevent or treat osteoporosis and dyspepsia. We describe a 78-year-old woman who presented with weakness, malaise, and confusion. She was found to have hypercalcemia, acute renal failure, and metabolic alkalosis. Upon further questioning, she reported use of large amounts of calcium carbonate tablets to treat recent heartburn symptoms. Calcium supplements were discontinued, and she was treated with intravenous normal saline. After 5 days, the calcium and bicarbonate levels normalized and renal function returned to baseline. In this article, we review the pathogenesis of the calcium-alkali syndrome as well as the differences between the traditional and modern syndromes.
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Affiliation(s)
- Mariangeli Arroyo
- Department of Internal Medicine, Baylor University Medical Center at Dallas
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32
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Fernández-García M, Vázquez L, Hernández JL. Calcium-alkali syndrome in post-surgical hypoparathyroidism. QJM 2012; 105:1209-12. [PMID: 21954111 DOI: 10.1093/qjmed/hcr179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Fernández-García
- Department of Internal Medicine, Hospital Marqués de Valdecilla, Avda, Valdecilla 25, 39008 Santander, Spain.
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Almusawi A, Alhawaj S, Al-Mousawi M, Dashti T. No more milk in milk-alkali syndrome: a case report. Oman Med J 2012; 27:413-4. [PMID: 23074554 DOI: 10.5001/omj.2012.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 08/03/2012] [Indexed: 11/03/2022] Open
Abstract
This is a case of Milk-AlKali syndrome in a patient who presented with the classical triad of hypercalcemia, metabolic alkalosis and renal impairment. The source of calcium was over-the-counter calcium-containing antacid (Tums®). Milk-alkali syndrome was first recognized secondary to treatment of peptic ulcer disease with milk and absorbable alkali. Its incidence fell after the introduction of H2-blocker and proton pump inhibitor. However, it is one of the leading causes of hypercalcemia nowadays because of the wide availability, increased marketing and use of calcium carbonate especially in osteoporosis prevention and treatment. The demographics of milk-alkali syndrome have changed compared to when it was initially described. The presentation could be acute, subacute or chronic. Early diagnosis, discounting calcium supplement and intravenous hydration are the mainstay of MAS management.
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Antacids, Altered Mental Status, and Milk-Alkali Syndrome. Case Rep Emerg Med 2012; 2012:942452. [PMID: 23431478 PMCID: PMC3546438 DOI: 10.1155/2012/942452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 12/11/2012] [Indexed: 11/17/2022] Open
Abstract
The frequency of milk-alkali syndrome decreased rapidly after the development of histamine-2 antagonists and proton pump inhibitors for the treatment of peptic ulcer disease; however, the availability and overconsumption of antacids and calcium supplements can still place patients at risk (D. P. Beall et al., 2006). Here we describe a patient who presented with altered mental status, hypercalcemia, metabolic alkalosis, and acute renal failure in the context of ingesting large amounts of antacids to control dyspepsia.
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Fernández García M, Riancho Moral JA, Hernández Hernández JL. Síndrome calcio-alcalinos: actualización de un antiguo problema clínico. Med Clin (Barc) 2011; 137:269-72. [DOI: 10.1016/j.medcli.2011.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/04/2011] [Accepted: 03/08/2011] [Indexed: 11/17/2022]
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Kolnick L, Harris BD, Choma DP, Choma NN. Hypercalcemia in pregnancy: a case of milk-alkali syndrome. J Gen Intern Med 2011; 26:939-42. [PMID: 21347876 PMCID: PMC3138978 DOI: 10.1007/s11606-011-1658-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 08/30/2010] [Accepted: 02/04/2011] [Indexed: 11/30/2022]
Abstract
Milk-alkali syndrome is a rare cause of hypercalcemia characterized by the triad of hypercalcemia, renal insufficiency, and metabolic alkalosis that results from the overconsumption of calcium containing products. In the setting of pregnancy where there is a physiologic increase in calcium absorption, milk-alkali syndrome can be potentially life threatening. We report a case of a 26-year-old woman in her second trimester of pregnancy who presented with 2 weeks of flank pain, nausea, vomiting, anorexia, headache, and lightheadedness. The history revealed consumption of a large quantity of milk, calcium carbonate antacid, and calcium-containing prenatal vitamins. Her symptoms and hypercalcemia resolved with intravenous fluids and a loop diuretic. With the increased use of calcium carbonate for peptic ulcer disease, gastroesophageal reflux disease, and osteoporosis, milk-alkali syndrome has experienced a resurgence and must be considered in the differential diagnosis of hypercalcemia. In this clinical vignette we review the literature on milk-alkali syndrome in pregnancy and discuss important diagnostic and therapeutic considerations when managing the pregnant patient with hypercalcemia.
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Affiliation(s)
- Leanne Kolnick
- Department of Medicine, Vanderbilt University Medical Center, D-3100 Medical Center North, Nashville, 37232 TN USA
| | - Bryan D. Harris
- Department of Medicine, Vanderbilt University Medical Center, D-3100 Medical Center North, Nashville, 37232 TN USA
| | - David P. Choma
- Department of Medicine, Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Neesha N. Choma
- Department of Medicine, Vanderbilt University Medical Center, D-3100 Medical Center North, Nashville, 37232 TN USA
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Affiliation(s)
- Rozalina Grubina
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - David L. Klocke
- Adviser to resident and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN
- Individual reprints of this article are not available. Address correspondence to David L. Klocke, MD, Division of Hospital Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Jeong JH, Bae EH. Hypercalcemia associated with acute kidney injury and metabolic alkalosis. Electrolyte Blood Press 2010; 8:92-4. [PMID: 21468203 PMCID: PMC3043759 DOI: 10.5049/ebp.2010.8.2.92] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 12/04/2010] [Indexed: 11/05/2022] Open
Abstract
Most cases of hypercalcaemia are secondary to malignancy or primary hyperparathyroidism. We report a patient presenting with a triad of hypercalcemia, metabolic alkalosis, and renal failure secondary to treatment of iatrogenic hypoparathyroidism and osteoporosis. Persistent ingestion of calcium carbonate and vitamin D caused milk-alkali syndrome. The patient was managed with intravenous fluids and withdrawal of calcium carbonate and vitamin D. She responded well to the treatment and the calcium concentration, renal function and metabolic alkalosis were normalized. Milk-alkali syndrome may be important as a reemerging cause of hypercalcemia.
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Affiliation(s)
- Jong Hyeok Jeong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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39
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Abstract
We recommend changing the name of the milk-alkali syndrome to the calcium-alkali syndrome, because the new terminology better reflects the shifting epidemiology and understanding of this disorder. The calcium-alkali syndrome is now the third most common cause of hospital admission for hypercalcemia, and those at greatest risk are postmenopausal or pregnant women. The incidence of the calcium-alkali syndrome is growing in large part as a result of the widespread use of over-the-counter calcium and vitamin D supplements. Advertising for treatment or prevention of osteoporosis has long encouraged this use. Intricate mechanisms mediating the calcium-alkali syndrome depend on interplay among intestine, kidney, and bone. New insights regarding its pathogenesis focus on the key role of calcium-sensing receptors and TRPV5 channels in the modulation of renal calcium excretion. Restoring extracellular blood volume, increasing GFR and calcium excretion, and discontinuing calcium supplementation provide best treatment.
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Affiliation(s)
- Ami M Patel
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Selvarajah M, Walter NM, Becker GJ. Hypercalcaemia--rapid relief. Intern Med J 2010; 39:e11. [PMID: 20233230 DOI: 10.1111/j.1445-5994.2009.02094.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Historically, the milk-alkali syndrome developed as an adverse reaction to the Sippy regimen of milk, cream and alkaline powders as treatment for peptic ulcer disease. The classic description includes hypercalcemia, metabolic alkalosis, and renal failure. Over the past 20 years, milk-alkali syndrome has had a resurgence, as consumption of supplements containing calcium has increased. A 46-year-old man presented to the emergency department after outpatient labs to evaluate his fatigue. He was found to have acute renal failure and hypercalcemia (total serum calcium was 15.9 mg/dL). Subsequent laboratory evaluation excluded both hyperparathyroidism and malignancy as causes. A detailed history led to the diagnosis of milk-alkali syndrome. With hydration and cessation of calcium carbonate ingestion, his renal function and serum calcium levels returned to normal. Physicians should have a high index of suspicion for milk-alkali syndrome in patients with hypercalcemia. Milk-alkali syndrome is no longer a merely a historical curiosity; it is currently the third most common cause of hypercalcemia.
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Affiliation(s)
- Kimberly Ulett
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Grubb M, Gaurav K, Panda M. Milk-alkali syndrome in a middle-aged woman after ingesting large doses of calcium carbonate: a case report. CASES JOURNAL 2009; 2:8198. [PMID: 20181207 PMCID: PMC2827131 DOI: 10.1186/1757-1626-0002-0000008198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 08/28/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Most cases of hypercalcaemia are secondary to malignancy or primary hyperparathyroidism. Here we report a case of hypercalcaemia that we have attributed to milk-alkali syndrome. CASE PRESENTATION A 51-year-old Caucasian woman with a past history of thyroidectomy and parathyroidectomy secondary to thyroid cancer developed an altered mental state and had an extremely high calcium concentration of 22.8 mg/dl (5.7 mmol/l). Investigations included work up for malignancy and hyperparathyroidism. However, the hypercalcaemia was attributed to ingestion of large doses of calcium carbonate, leading to milk-alkali syndrome. She was managed with intravenous fluids and withdrawal of calcium carbonate. The patient responded well to treatment, with normalization of the calcium concentration and clinical improvement. CONCLUSION We present this case to remind clinicians of the importance of detailed history taking and of milk-alkali syndrome as a cause of hypercalcemia.
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Affiliation(s)
- Mandy Grubb
- Department of Medicine, University of Tennessee, College of Medicine, 960 East Third Street, Suite 208, Chattanooga, TN 37403, USA
| | - Kumar Gaurav
- Department of Internal Medicine, Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Mukta Panda
- Department of Medicine, University of Tennessee, College of Medicine, 960 East Third Street, Suite 208, Chattanooga, TN 37403, USA
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Hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention--'modern' milk alkali syndrome: a case report. CASES JOURNAL 2009; 2:6188. [PMID: 19918560 PMCID: PMC2769270 DOI: 10.4076/1757-1626-2-6188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 05/05/2009] [Indexed: 11/08/2022]
Abstract
We report a case of a patient presenting with a triad of hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention. It is the classical presentation of the "modern" milk alkali syndrome that presents several characteristics distinguishing it from the "old" syndrome described secondary to peptic ulcer disease treatment. Milk alkali syndrome affects middle-aged female patients taking over-the-counter calcium carbonate. Clinically, these patients present in an acute hypercalcemia crisis, responding rapidly to hydration. The phosphorus level is normal to low. Bisphosphonate should be used cautiously due to the risk of symptomatic hypocalcemia.
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Hanada S, Iwamoto M, Kobayashi N, Ando R, Sasaki S. Calcium-Alkali Syndrome Due to Vitamin D Administration and Magnesium Oxide Administration. Am J Kidney Dis 2009; 53:711-4. [DOI: 10.1053/j.ajkd.2008.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 11/04/2008] [Indexed: 11/11/2022]
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Abstract
Milk-alkali syndrome (MAS) consists of hypercalcemia, various degrees of renal failure, and metabolic alkalosis due to ingestion of large amounts of calcium and absorbable alkali. This syndrome was first identified after medical treatment of peptic ulcer disease with milk and alkali was widely adopted at the beginning of the 20th century. With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention. The aim of this review was to determine the incidence, pathogenesis, histologic findings, diagnosis, and clinical course of MAS. A MEDLINE search was performed with the keyword milk-alkali syndrome using the PubMed search engine. All relevant English language articles were reviewed. The exact pathomechanism of MAS remains uncertain, but a unique interplay between hypercalcemia and alkalosis in the kidneys seems to lead to a self-reinforcing cycle, resulting in the clinical picture of MAS. Treatment is supportive and involves hydration and withdrawal of the offending agents. Physicians and the public need to be aware of the potential adverse effects of ingesting excessive amounts of calcium carbonate.
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Affiliation(s)
- Boris I Medarov
- Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, 1200 N State St, GNH-11900, Los Angeles, CA 90033, USA.
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Abstract
Milk-alkali syndrome (MAS) consists of hypercalcemia, various degrees of renal failure, and metabolic alkalosis due to ingestion of large amounts of calcium and absorbable alkali. This syndrome was first identified after medical treatment of peptic ulcer disease with milk and alkali was widely adopted at the beginning of the 20th century. With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention. The aim of this review was to determine the incidence, pathogenesis, histologic findings, diagnosis, and clinical course of MAS. A MEDLINE search was performed with the keyword milk-alkali syndrome using the PubMed search engine. All relevant English language articles were reviewed. The exact pathomechanism of MAS remains uncertain, but a unique interplay between hypercalcemia and alkalosis in the kidneys seems to lead to a self-reinforcing cycle, resulting in the clinical picture of MAS. Treatment is supportive and involves hydration and withdrawal of the offending agents. Physicians and the public need to be aware of the potential adverse effects of ingesting excessive amounts of calcium carbonate.
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Affiliation(s)
- Boris I Medarov
- Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, 1200 N State St, GNH-11900, Los Angeles, CA 90033, USA.
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Bailey CS, Weiner JJ, Gibby OM, Penney MD. Excessive calcium ingestion leading to milk-alkali syndrome. Ann Clin Biochem 2008; 45:527-9. [DOI: 10.1258/acb.2008.008006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This report describes the presentation and clinical course of a 40-year-old woman who had an emergency admission for eclampsia. During routine investigations, she was found to have profound hypercalcaemia, the cause of which was identified as milk-alkali syndrome, caused by self-medication with antacid tablets for dyspepsia. Treatment with aggressive rehydration, bisphosphonates and discontinuation of antacid tablets restored normocalcaemia. The patient made a full recovery with no long-term side-effects. Her male infant was safely delivered with no deleterious effects of exposure to high calcium concentrations in utero.
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Affiliation(s)
| | - J J Weiner
- Department of Obstetrics and Gynaecology
| | - O M Gibby
- Department of Endocrinology, Royal Gwent Hospital, Cardiff Road, Newport, South Wales NP20 2UB, UK
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Herlitz LC, Bruno R, Radhakrishnan J, Markowitz GS. A case of nephrocalcinosis. Kidney Int 2008; 75:856-9. [PMID: 18615001 DOI: 10.1038/ki.2008.298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Leal C Herlitz
- Department of Pathology, Columbia University, New York, New York 10032, USA
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Irtiza-Ali A, Waldek S, Lamerton E, Pennell A, Kalra PA. Milk alkali syndrome associated with excessive ingestion of Rennie: case reports. J Ren Care 2008; 34:64-7. [PMID: 18498570 DOI: 10.1111/j.1755-6686.2008.00018.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Milk alkali syndrome is a cause of hypercalcaemia, renal failure and alkalosis, and is potentially reversible if detected early and the calcium and alkali source withdrawn. It was originally described in patients ingesting large amounts of calcium containing milk for the treatment of peptic ulcer disease. We present a modern day version of the syndrome in three cases which were associated with excessive intake of Rennie, a calcium carbonate containing antacid.
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Affiliation(s)
- Ayesha Irtiza-Ali
- Department of Renal Medicine, Hope Hospital, Salford, Manchester, UK.
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50
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Affiliation(s)
- Ilan Gabriely
- Division of Endocrinology and Metabolism, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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