Abstract
Depending on each institution's laboratory test, mean serum calcium levels range between 8.8 and 10.8 mg/dL and hypercalcemia is defined as two standard deviations above the mean. According to recent epidemiological studies, 90% of cases of hypercalcemia are due to hyperparathyroidism or malignancy. Milk Alkali syndrome (MAS) also known as Calcium Alkali syndrome (CAS) is the third biggest cause of hypercalcemia, but its incidence seems to be higher than previously thought. Here we present a case of Calcium Alkali Thiazide syndrome (CATS) in a 57-year-old female who was on calcium and vitamin D supplements (after parathyroidectomy) while also taking thiazide diuretic for hypertension. She was brought to the ED with nausea, vomiting, confusion, difficulty walking along with numbness in extremities. She had parathyroidectomy three weeks ago. During history taking, patient reported intake of calcium carbonate 1 g three times daily, calcitriol 0.5 mcg twice daily, cholecalciferol (vitamin D3) 10,000 units once daily, chlorthalidone 25 mg once daily and irbesartan 300 mg once daily. At admission, her calcium level was 23 mg/dL, ionized calcium 12.03 mg/dL, pH was 7.59 and HCO3 was 33. She was in renal failure with creatinine of 1.9 mg/dL (baseline 0.8 mg/dL). Her parathyroid hormone (PTH) level was 0. A diagnosis of CATS was made. She was treated with intravenous fluids and furosemide and discharged home on hospital day 5 after her calcium and creatinine levels normalized. A triad of hypercalcemia, acute kidney injury and metabolic alkalosis comprises MAS. Traditional MAS was caused by "Sippy diet" (containing milk and alkali) used for the treatment of peptic ulcer disease. Over the decades, the same triad of symptoms occurred in patients using excess calcium and vitamin D, hence changing the name to CAS. A subset of patients at risk for CAS also use thiazide diuretics for hypertension, making them more vulnerable to hypercalcemia and acute kidney injury. In such subset of patients, it is preferable to use the term CATS rather than MAS or CAS.
Highlights
Calcium level above 10.5 mg/dL is considered abnormal but depending on each institution's laboratory, mean serum calcium levels can range from 8.8 to 10.8 mg/dL
We present here an interesting case of Calcium Alkali syndrome (CAS) in a patient who was taking an excessive amount of calcium and vitamin D while concurrently being treated with thiazide diuretic for hypertension
What if AKI is associated with alkalosis and not acidosis? Interesting isn’t it? What if elevated bicarbonate and creatinine level are associated with hypercalcemia? The triad of metabolic alkalosis, hypercalcemia and acute kidney injury are the hallmark of Milk Alkali syndrome (MAS)/CAS, which is regarded as the third most common cause of hypercalcemia after hyperparathyroidism and malignancy [4]
Summary
Calcium level above 10.5 mg/dL is considered abnormal but depending on each institution's laboratory, mean serum calcium levels can range from 8.8 to 10.8 mg/dL. Patient’s initial laboratory values showed white blood cell (WBC) count of 15.5 k/mm, hemoglobin (Hb) of 15.6 gm/dL, platelet count of 370 k/mm 3, creatinine of 1.9 mg/dL (baseline was 0.8), BUN of 45 mg/dL, eGFR of 27 mL/min (baseline eGFR >60 mL/min), bicarbonate of 33 mEq/L, chloride of 94 mEq/L, potassium of 2.5 mEq/L, sodium of 135 mEq/L, total calcium of 23 mg/dL with ionized calcium of 12.03 mg/dL, phosphate of 1.3 mg/dL and PTH of 0 Her 25 hydroxyvitamin D level was 61 ng/mL (normal 30-100 ng/mL) and 1-25 hydroxyvitamin D3 level was 31 pg/ml (normal 18-72 pg/mL) (Table 1). When asked about medication history, patient reported 3 g calcium carbonate intake daily, calcitriol 0.5 mcg twice daily, cholecalciferol (vitamin D3) 10,000 units once daily, chlorthalidone 25 mg once daily and irbesartan 300 mg once daily Her diet included a glass of milk after each meal. Her creatinine levels were close to baseline at 1.4 mg/dL on the day of discharge
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