scholarly journals The use of hemodialysis in hypercalcemic crisis secondary to primary hyperparathyroidism

2021 ◽  
Vol 35 (2) ◽  
Author(s):  
Catarina Marouço ◽  
◽  
Fernando Caeiro ◽  
Bernardo Costa ◽  
David Navarro ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Medical Therapy ◽  
Mental Status ◽  
Kidney Injury ◽  
Altered Mental Status ◽  
Medical Emergency ◽  
Hypercalcemic Crisis ◽  
Standard Medical Therapy ◽  
Severe Hypercalcemia ◽  
Stage Renal Disease

Severe hypercalcemia can be either acute or decompensate from a chronic state to a medical emergency, the hypercalcemic crisis. The presence of symptoms such as altered mental status or potentially fatal ECG abnormalities demand an expeditious decrease in serum calcium levels. Standard medical therapy consists of vigorous volume replacement, calcitonin and, depending on the etiology, bisphosphonates, cinacalcet or glucocorticoids. Hypercalcemic crisis is a rare indication for urgent hemodialysis and is reserved for patients with severe symptoms, ineffective medical therapy or end stage renal disease. The use of hemodialysis in this scenario is not commonly reported. We hereby report a patient who presented with altered mental status and acute kidney injury due to a hypercalcemic crisis secondary to primary hyperparathyroidism. Treatment included urgent hemodialysis to effectively lower calcium levels.

scholarly journals PROLONGED HYPERCALCEMIA FROM ANTIBIOTIC-ELUTING CALCIUM SULFATE BEADS

2019 ◽  
Vol 5 (6) ◽  
pp. e349-e351 ◽  
Author(s):  
Amy Vora ◽  
Sadia Ali
Keyword(s):  
Renal Failure ◽  
Mental Status ◽  
Serum Calcium ◽  
Calcium Sulfate ◽  
Volume Overload ◽  
Altered Mental Status ◽  
Caucasian Woman ◽  
Local Antibiotics ◽  
Joint Infections ◽  
Severe Hypercalcemia

Objective: Calcium sulfate beads (CSBs) are biocompatible hydrophilic crystals that are used to deliver local antibiotics in periprosthetic joint infections. Hypercalcemia after placement of CSBs is uncommon and poorly understood. Methods: We present the case of a woman who presented with symptomatic hypercalcemia after placement of antibiotic-eluting CSBs. Results: A 58-year-old, Caucasian woman presented with altered mental status, respiratory failure, and septic shock 2 days after placement of antibiotic-eluting CSBs for a left prosthetic hip infection. Laboratory analysis revealed severe hypercalcemia at presentation. She had no known history of fractures, kidney stones, parathyroid, or calcium disorders. She was not on any medications that could induce hypercalcemia. She was treated with aggressive intravenous hydration and 8 doses of calcitonin. Due to impaired renal function, bisphosphonate was contraindicated. She subsequently became anuric with worsening renal failure and volume overload and the decision was made to initiate dialysis. She received 8 days of continuous renal replacement therapy followed by 2 sessions of hemodialysis which improved her serum calcium levels, mental status, and renal failure with no long-term complications. Conclusion: Hypercalcemia secondary to the placement of antibiotic-eluting CSBs is rare. Larger volumes of CSBs may contribute to hypercalcemia. In some cases, hypercalcemia can be severe and symptomatic as in the case of our patient. Serum calcium levels should be monitored frequently after placement of CSBs and managed as appropriate.

scholarly journals Posterior Reversible Encephalopathy Syndrome: A Case of Hypercalcemia

2018 ◽  
Vol 31 (6) ◽  
pp. 338
Author(s):  
Ana Ponciano ◽  
Vera Vieira ◽  
José Leite ◽  
Célio Fernandes
Keyword(s):  
Renal Failure ◽  
Immunosuppressive Therapy ◽  
Mental Status ◽  
Posterior Reversible Encephalopathy Syndrome ◽  
Altered Mental Status ◽  
Normotensive Patient ◽  
Posterior Reversible Encephalopathy ◽  
Severe Hypercalcemia ◽  
Reversible Encephalopathy

Posterior reversible encephalopathy syndrome is an encephalopathy that can be clinically characterized by headache, altered mental status and/or seizures. Neuroimaging demonstrates usually reversible bilateral subcortical vasogenic occipital-parietal edema. Exact pathophysiology remains unclear but is commonly associated with hypertension, renal failure, sepsis and use of immunosuppressive therapy. Its development in the setting of severe hypercalcemia is extremely rare. The authors report a case of posterior reversible encephalopathy syndrome in a normotensive patient with severe hypercalcemia as the only identifiable cause.

scholarly journals MON-LB65 Lithium: The Culprit of Multiple Endocrinopathies

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Alice Yau ◽  
Gul Bahtiyar ◽  
Giovanna Rodriguez ◽  
Jose R Martinez Escudero
Keyword(s):  
Bipolar Disorder ◽  
Diabetes Insipidus ◽  
Mental Status ◽  
Nephrogenic Diabetes Insipidus ◽  
Kidney Injury ◽  
Urine Osmolality ◽  
Altered Mental Status ◽  
Clinical Findings ◽  
Volume Depletion ◽  
Collecting Tubules

Abstract Background: Lithium, commonly used to treat various psychiatric disorders such as bipolar disorder, can cause acute toxicity that presents with nausea, vomiting and diarrhea. Lithium can also cause life-threatening endocrine abnormalities, including hypercalcemia, hypernatremia, and both hypo- and hyperthyroidism. Clinical Case: A 61-year old female with hypothyroidism, bipolar disorder, hyperparathyroidism with two-gland parathyroidectomy on lithium for over 30 years presented with altered mental status. Initial labs revealed elevated creatinine 1.92 mg/dL (0.8-2.00mg/dL) compared to baseline 0.82 mg/dL, sodium 154 mg/dL (135-147 mg/dL), Corrected calcium 11.7 mg/dL (8.5-10.5 mg/dL), PTH 96 pg/mL (15-65 pg/mL), and high lithium levels 1.45 mmol/L (0.60-1.20 mmol/L). Further studies showed hypotonic polyuria with no increase in urine osmolality after desmopressin, consistent with nephrogenic diabetes insipidus. Lithium was held and she was treated with aggressive intravenous hydration with dextrose 5% water. Hypercalcemia is thought to result from increased secretion of PTH due to an increased set point at which calcium suppresses PTH release; this often resolves once lithium is stopped. Lithium can also unmask previously unrecognized mild hyperparathyroidism, and/or raise serum PTH concentrations independent of calcium levels.1 The drug interferes with the kidneys’ ability to concentrate urine in the collecting tubules by desensitizing response to antidiuretic hormone, causing diabetes insipidus. The resulting volume depletion from excessive urinary water loss in turn lead to acute kidney injury and hypernatremia.2 Hypothyroidism results from lithium-inhibited synthesis and release of thyroid hormones and decreases iodine trapping. Conclusion: Although these are infrequent complications of lithium use, they remain pertinent clinical findings to consider due to their morbidity. In this case, our patient may have avoided multiple chronic electrolyte abnormalities leading to altered mental status if lithium toxicity had been recognized earlier. References:1. García-Maldonado, Gerardo, and Rubén de Jesús Castro-García. “Endocrinological Disorders Related To The Medical Use Of Lithium. A Narrative Review”. Revista Colombiana De Psiquiatría (English Ed.), vol 48, no. 1, 2019, pp. 35-43. Elsevier BV, doi:10.1016/j.rcpeng.2018.12.005. 2. Tasci, E. “Lithium-Induced Nephrogenic Diabetes Insipidus Responsive To Desmopressin”. Acta Endocrinologica (Bucharest), vol 15, no. 2, 2019, pp. 270-271. ACTA Endocrinologica Foundation, doi:10.4183/aeb.2019.270.

Ertapenem-induced encephalopathy

2020 ◽  
Vol 13 (6) ◽  
pp. e231875
Author(s):  
Rebecca Adams ◽  
Priya Chopra ◽  
Richard Miranda ◽  
Aaron Calderon
Keyword(s):  
Intensive Care Unit ◽  
Mental Status ◽  
End Stage Renal Disease ◽  
Filtration Rate ◽  
Estimated Glomerular Filtration Rate ◽  
Kidney Injury ◽  
Visual Hallucinations ◽  
Airway Protection ◽  
Stage Renal Disease ◽  
End Stage

Neurotoxicity is an unusual side effect of carbapenems, and it has been reported most commonly presenting as seizures, encephalopathy and hallucinations. Ertapenem neurotoxicity most classically presents as seizures in patients with end-stage renal disease (estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2). We present a patient with a baseline eGFR of 30–59 mL/min/1.73 m2 with acute kidney injury who developed non-seizure neurotoxicity after ertapenem exposure. This patient is a middle-aged Caucasian man who received intravenous ertapenem for treatment of empyema. Although the empyema improved, he developed delirium beginning on day 7 of ertapenem. The delirium progressed to constant agitation and visual hallucinations requiring transfer to the intensive care unit with eventual intubation for airway protection. No improvement in mental status was observed with cessation of other medications. Ertapenem was discontinued and within 24 hours, he was extubated, and his mental status returned to baseline. He was discharged from the hospital the following day. The timely resolution after ertapenem discontinuation makes ertapenem-induced encephalopathy the most likely explanation for this patient’s course.

Myoclonus and Altered Mental Status Induced by Single Dose of Gabapentin in a Patient With End-Stage Renal Disease

2019 ◽  
Vol 26 (6) ◽  
pp. e768-e770 ◽  
Author(s):  
Ahmed Yeddi ◽  
Omeralfaroug Adam ◽  
Mowyad Khalid ◽  
Sindhuri Benjaram ◽  
Ahmad Abu-Heija ◽  
...  
Keyword(s):  
Single Dose ◽  
Renal Disease ◽  
Mental Status ◽  
End Stage Renal Disease ◽  
Altered Mental Status ◽  
Stage Renal Disease ◽  
End Stage

scholarly journals MON-370 Treatment of Parathyroid Storm in a Patient with Traumatic Brain Injury: A Reversible Comatose State

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Jane Rhyu ◽  
Jeffrey Wei ◽  
Christine Hema Darwin
Keyword(s):  
Traumatic Brain Injury ◽  
Acute Kidney Injury ◽  
Brain Injury ◽  
Mental Status ◽  
Injury Risk ◽  
Clavicle Fracture ◽  
Kidney Injury ◽  
Cystic Degeneration ◽  
Severe Hypercalcemia ◽  
Comatose State

Abstract Background: Parathyroid storm, also known as parathyroid crisis, is a rare and under-recognized endocrine emergency due to severe hypercalcemia in patients with primary hyperparathyroidism. It is characterized by significantly elevated parathyroid hormone (PTH) levels even up to 20 times above the normal limit along with calcium levels &gt;15 mg/dl, leading to multiorgan dysfunction, notably altered mental status and acute kidney injury. Risk of mortality is high without urgent parathyroidectomy. We describe a case of a patient with acute traumatic brain injury and parathyroid storm with PTH &gt;1700 pg/ml (11-51) and Ca 15.4 mg/dl (8.6-10.4) in whom resection of a parathyroid adenoma reversed the comatose state. Clinical Case: Our patient is a 68 year-old male with no significant past medical history who sustained a fall off a 12-foot ladder complicated by right intracranial bleed s/p hemicraniectomy and multiple fractures, including left clavicle fracture with possible subclavian artery injury, left rib fractures, and right hip fracture s/p ORIF. The patient had a brief, partial improvement of mental status, followed by comatose state in the setting of rapidly rising calcium levels and acute kidney injury. In the setting of blood transfusions, the patient had an initial Ca of 8.8 mg/dl (8.6-10.4) on admission. The calcium levels rose over a week to 15.4 mg/dl with albumin of 2.4 g/dl (3.9-5.0), PTH levels from 953 pg/ml to &gt;1700 pg/ml (11-51) after tracheostomy, and creatinine from 0.69 mg/dl to peak of 2.0 mg/dl (0.60-1.30). In spite of IV hydration, calcitonin, cinacalcet up to 90mg twice daily, pamidronate 60mg IV, and several sessions of hemodialysis, the patient’s calcium did not normalize, and the patient remained comatose. Other labs showed phosphorus nadir of 1.4 mg/dl (2.3-4.4), 25-OH VitD 13 ng/ml (20-50), 1,25-OH VitD 9.8 pg/ml (19.9-79.3), VitA 0.6 mg/L (0.3-0.9), PTHrP &lt;2.0 pmol/L (0.0-2.3), normal SPEP/UPEP, and peak CK of 569 U/L (63-474). Sestamibi scan showed intense tracer uptake within a nodule near the suprasternal notch, and parathyroid 4D-CT showed a left 17mm pretracheal lesion with cystic degeneration along the superior margin of the manubrium. The patient subsequently underwent parathyroidectomy of an ectopic cystic mass with normalization of calcium and PTH levels. Pathology revealed a 0.8 gram, 1.5 x 1.0 x 0.3 cm enlarged, hypercellular parathyroid. The patient woke up from his comatose state immediately after surgery with progressive improvement in mental status back to baseline, other than left-sided weakness. Conclusion: Our case highlights the importance of surgical management as an effective cure for parathyroid crisis and underscores the associated critical and significant rise in calcium and PTH levels, which was resistant to medical treatment.

scholarly journals Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

PLoS ONE ◽  
2021 ◽  
Vol 16 (10) ◽  
pp. e0258095
Author(s):  
Abdallah S. Attia ◽  
Mohammad Hussein ◽  
Mohamed A. Aboueisha ◽  
Mahmoud Omar ◽  
Mohanad R. Youssef ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Cohort Study ◽  
Mental Status ◽  
Delayed Diagnosis ◽  
Clinical Manifestations ◽  
Kidney Injury ◽  
Altered Mental Status ◽  
Neurological Manifestations ◽  
Icu Admission ◽  
Poor Outcomes

Introduction Several studies have described typical clinical manifestations, including fever, cough, diarrhea, and fatigue with COVID-19 infection. However, there are limited data on the association between the presence of neurological manifestations on hospital admission, disease severity, and outcomes. We sought to investigate this correlation to help understand the disease burden. Methods We delivered a multi-center retrospective study of positive laboratory-confirmed COVID-19 patients. Clinical presentation, laboratory values, complications, and outcomes data were reported. Our findings of interest were Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and in-hospital mortality. Results A total of 502 patients with a mean age of 60.83 ± 15.5 years, of them 71 patients (14.14%) presented with altered mental status, these patients showed higher odds of ICU admission (OR = 2.06, 95%CI = 1.18 to 3.59, p = 0.01), mechanical ventilation (OR = 3.28, 95%CI = 1.86 to 5.78, p < 0.001), prolonged (>4 days) mechanical ventilation (OR = 4.35, 95%CI = 1.89 to 10, p = 0.001), acute kidney injury (OR = 2.18, 95%CI = 1.28 to 3.74, p = 0.004), and mortality (HR = 2.82, 95%CI = 1.49 to 5.29, p = 0.01). Conclusion This cohort study found that neurological presentations are associated with higher odds of adverse events. When examining patients with neurological manifestations, clinicians should suspect COVID-19 to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

scholarly journals Vitamin A and Hydrochlorothiazide Causing Severe Hypercalcemia in a Patient With Primary Hyperparathyroidism

2019 ◽  
Vol 7 ◽  
pp. 232470961882380 ◽  
Author(s):  
Ron T. Varghese ◽  
Khaled Khasawneh ◽  
Raman K. Desikan ◽  
Anandaraj Subramaniam ◽  
Todd Weaver ◽  
...  
Keyword(s):  
Vitamin D ◽  
Vitamin A ◽  
Primary Hyperparathyroidism ◽  
Public Awareness ◽  
Altered Mental Status ◽  
Response To Therapy ◽  
White Female ◽  
Laboratory Findings ◽  
Severe Hypercalcemia ◽  
The Right

Objective. To report a case of severe hypercalcemia, exacerbated by vitamin A supplementation and hydrochlorothiazide, in a patient with primary hyperparathyroidism. Methods. Clinical and laboratory findings are presented along with response to therapy. Results. A 68-year-old white female presented to the emergency department complaining of nausea, vomiting, and altered mental status. Laboratory findings revealed calcium 15.8 mg/dL (8.4-10.2), albumin 4.1 g/dL (3.8-4.8), and parathyroid hormone 62 pg/mL (14-64). Serum calcium improved after intravenous hydration with normal saline. Prior to this hospitalization, over-the-counter medications were significant for calcium (600 mg daily), vitamin A (11 000 IU daily), and vitamin D (800 IU daily).The patient’s prescription medications were significant for hydrochlorothiazide (12.5 mg daily). Twenty-four-hour urine calcium was subsequently found to be 146 mg (35-250). Myeloma, lymphoma, and sarcoidosis were ruled out as the etiology for hypercalcemia. The diagnosis of primary hyperparathyroidism was confirmed. She was treated surgically for primary hyperparathyroidism. The right and left superior parathyroid showed hypercellular parathyroid on pathology. The patient was normocalcemic after surgery. Conclusion. Previous reports suggest that very high doses of vitamin A is required to cause hypercalcemia. This case suggests that in a setting of primary hyperparathyroidism and hydrochlorothiazide therapy, vitamin A may contribute to the development of severe hypercalcemia in patients who are on calcium and vitamin D supplements. Given their biologic effects, public awareness needs to be created regarding the injudicious use of vitamins.

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