Case Report

An Unrecognized Cause of Recurrent Hypercalcemia: Immobilization

Authors: Chih-Jen Cheng, MD, Chung-Hsing Chou, MD, Shih-Hua Lin, MD

Abstract

Abstract:We report a 66-year-old Chinese man with chronic renal insufficiency (creatinine 1.7 mg/dL) and gout suffering from slurred speech and right hemiplegia for 3 days. Acute cerebral infarction was confirmed by computed tomography. Conscious disturbance occurred on the tenth hospital day without significant changes on imaging study when compared with a previous scan. Hypercalcemia (total calcium 14.1 mg/dL) and acute exacerbation of chronic renal failure (serum creatinine 2.5 mg/dL) were noticed. Hypercalciuria (FECa 3.2%), and low serum levels of intact parathyroid hormone and 1,25(OH)2D3 suggested nonparathyroidal hypercalcemia. An extensive workup failed to identify any etiology of hypercalcemia. Hypercalcemia and renal failure were temporarily ameliorated after aggressive volume expansion and loop diuretic treatment but recurred 2 weeks later. Immobilization hypercalcemia was considered after the exclusion of other discernible causes and was successfully treated with rehabilitative exercises and bisphosphonates without further recurrence during a 2-year follow-up. Clinical alertness to immobilization as a possible cause of hypercalcemia may avoid unnecessary and invasive examinations, life-threatening complications and annoying recurrences.

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References

1. Ziegler R. Hypercalcemic crisis. J Am Soc Nephrol 2001;12:S3–9.
 
2. Albright F, Burnett CH, Cope O, et al. Acute atrophy of bone (osteoporosis) simulating hyperparathyroidism. J Clin Endocrinol 1941;1:711–716.
 
3. Stewart AF, Adler M, Byers CM, et al. Calcium homeostasis in immobilization: an example of resorptive hypercalciuria. N Engl J Med 1982;306:1136–1140.
 
4. Drivas G, Ward M, Kerr D. Immobilization hypercalcaemia in patients on regular haemodialysis. Br Med J 1975;3:468.–
 
5. Gopal H, Sklar AH, Sherrard DJ. Symptomatic hypercalcemia of immobilization in a patient with end-stage renal disease. Am J Kidney Dis 2000;35:969–972.
 
6. Lin SH, Lin YF, Cheema-Dhadli S, et al. Hypercalcaemia and metabolic alkalosis with betel nut chewing: emphasis on its integrative pathophysiology. Nephrol Dial Transplant 2002;17:708–714.
 
7. Henriquez-Kries D, Sommerer C, Dikow R, et al. Hypercalcaemia-induced renal failure—a mystery.Nephrol Dial Transplant 2002;17:677–678.
 
8. Tori JA, Hill LL. Hypercalcemia in children with spinal cord injury. Arch Phys Med Rehabil1978;59:443–446.
 
9. Bikle DD, Halloran BP. The response of bone to unloading. J Bone Miner Metab 1999;17:233–244.
 
10. Krieger NS, Sessler NE, Bushinsky DA. Acidosis inhibits osteoblastic and stimulates osteoclastic activity in vitro. Am J Physiol 1992;262:F442–F448.
 
11. Raisz LG. Bone resorption in tissue culture: Factors influencing the response to parathyroid hormone. J Clin Invest 1965;44:103–116.
 
12. Sato Y. Abnormal bone and calcium metabolism in patients after stroke. Arch Phys Med Rehabil2000;81:117–121.
 
13. Jorgensen L, Jacobsen BK, Wilsgaard T, et al. Walking after stroke: does it matter? Changes in bone mineral density within the first 12 months after stroke. A longitudinal study. Osteoporos Int2000;11:381–387.
 
14. Wang W, Li C, Kwon TH, et al. Reduced expression of renal Na+ transporters in rats with PTH-induced hypercalcemia. Am J Physiol 2004;286:F534–F545.
 
15. Sato Y, Asoh T, Kaji M, et al. Beneficial effect of intermittent cyclical etidronate therapy in hemiplegic patients following an acute stroke. J Bone Miner Res 2000;15:2487–2494.