week-end call and a pair of crazy numbers: Glucose and Calcium

I saw the highest glucose I can remember in a patient without ESRD. I have seen the glucose go over 2,700 in a patient with the misfurtune to have both DKA and anuric ESRD. Without the osmotic diuresis to lower the glucose the glucose can shoot the moon. This patient had HyperOsmolar Non-Ketotic Coma (or HONK as my fellow calls it, love that) and baseline Cr of 0.83 and a peak glucose of 1,600 mg/dL.
I love the twin graphs showing the falling glucose and the simultaneous resolution of the pseudohyponatremia. The patient had enough pre-existing osmotic diuresis to cause hypernatremia which was masked by the hyperglycemia. As the glucose comes down the sodium goes up from 136 to 162.

The other crazy number was the most severe hypercalcemia I have ever seen. The calcium was 18 mg/dL with an albumin of 3.7 g/dL. The patient is a kidney transplant recipient who was recently seen in the outpatient clinic with hypocalcemia. His calcium was 6.5 and his calcitriol was increased from 0.5 mcg to 1 mcg twice daily. He was also continued on his calcium carbonate.

Admission labs:

The other pertinent calcium labs:

  • PTH: 3.2 pg/mL
  • Vit D 1,25 dihydroxy: 36 pg/mL
  • SPEP/UPEP: unremarkable
  • PTHrp: pending
I think this is milk-alkali syndrome from the calcium carbonate exacerbated by the calcitriol. One supporting string of evidence supporting this is the fact that his calcium came down and has not reoccurred. If it was hypercalcemia of malignancy I would have expected his calcium to be resistant to conservative therapy.  

7 Replies to “week-end call and a pair of crazy numbers: Glucose and Calcium”

  1. One would expect the serum PTH not measurable with such a high calcium concentration. I expect that this is not just overdosing of calcium. I would suggest that this Tx pt has a tertiary hyperpara which is somewhat supressed now by the high serum Ca. Remeasure the PTH when the calcium is normal. It will probably show a high value.

  2. Rene, do you think the PTH is driving the hypercalcemia? I don't. I agree that he probably has some autonomous parathyroid tissue but I doubt it is clinically significant. Its hard for me to beleive that a PTH of 3 is a significant factor in his high calcium.

  3. Joel I think it is a combination of factors. I think this patient has lower bone buffer capacity for the administrated calcium which is he was absorbing more avidly by the increase in vitamine D. This might be the result of a tertiary hyperpth. Thus I think it is rather a combination of factors. With such a high calcium one would expect the PTH to be undetectable.
    Alternatively the patient might have adynamic bone disease despite hyperparathyroidism. This might be the result of alumunum toxicity on the bone which he might have used for some while in his dialysis days. Also a combination of factors.

    Does anyone have another explanation?

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