I started this calcium series in January. This was the second lecture. The fellows are clever so instead of a formal lecture the presentation is designed to stimulate discussion and pose a number questions using real cases.
Hypercalcemia from 1,25 vitamin D toxicity
I received an outpatient consult for acute kidney injury. One of the things that makes Saint Clair Nephrology a remarkable nephrology group is our ability to get patients in quickly. While competing practices in the area have a 3-month wait list to see new patients we get patients in within a week. This patient was seen two days after his doctor called.
The patient was frightened. He had previously been healthy and his doctor told him his kidneys were failing and that he needed to see a nephrologist. He arrived with a creatinine in the high 2s from a base line of 1.2 mg/dL. Along with the AKI his blood pressure was touching 180 systolic, out of character for him. Of note on the initial labs his calcium was 13.6 mg/dL.
The initial work-up showed suppressed PTH. SPEP and UPEP were normal.
On the next visit I checked the 1,25 vitamin D and it was 117 IU. I suspected lymphoma or sarcoidosis but the chest x-ray was unremarkable and the patient did not have any palpable lymph nodes or abnormalities on the CBC. No weight loss, night sweats, or fevers. ACE levels were unremarkable.
On further questioning on his third visit, the patient mentioned he was taking a generic knock off of Mega Red Fish Oil. Fish oils can have significant amounts of vitamin D and the supplement is famously lax with quality control. He stopped the fish oil, we started him on oral prednisone and the 1,25 vitamin D level quickly responded within a couple of weeks. The patient had a full recovery from the hypercalcemia, hypertension, and acute kidney injury.
Update
Some great comments from Twitter
Why did you start steroids if sarcoidosis was low in your ddx?
— Adam Bregman (@abregman42) January 11, 2018
steroids lower 1,25 vitamin D levels
— Joel M. Topf, MD FACP (@kidney_boy) January 11, 2018
Steroids only work if there’s a granuloma right? But this was an external source…
— Anitha Vijayan (@VijayanMD) January 11, 2018
Good question. Found this: https://t.co/TxUB2LdPqh
Agree, not the most compelling.
— Joel M. Topf, MD FACP (@kidney_boy) January 11, 2018
This is much better from the @NEJM in 1969. Just a couple of months shy of my birthday.https://t.co/Res8GKCDSF pic.twitter.com/KjPz1Jzdo1
— Joel M. Topf, MD FACP (@kidney_boy) January 11, 2018
Lecture for the St John Residents
I have been doing a monthly fluid and electrolyte conference for the residents at St. John. Today we did a case of hypernatremia initially due to hypercalcemia and then due to nephrogenic diabetes insipidus.
Hypernatremia Hypercalcemia Case Vignette
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Lecture at Providence Hospital on Electrolytes
I am trying to do a monthly lecture for the Providence internal medicine residents on electrolytes. I gave my second one last Friday. It was an interesting case we had of hypernatremia on the consult service last summer.
I did this lecture in Keynote and I am blown away by how good it presents through SlideShare. Really impressive.
Hypernatremia Hypercalcemia Case Vignette
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