Management of Hyperacute Severe Hypercalcemia of Occult Malignancy

Abstract

SESSION TITLE: Hematology and Oncology Disorders SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: A patient with no Chronic Kidney Disease nor known malignancy presented with a marked increase in serum calcium over 4 days manifesting as ventricular tachycardia (VT) and loss of consciousness. Severe hypercalcemia is a cardiac emergency that may necessitate emergent hemodialysis. CASE PRESENTATION: A 69 year old Afro-Jamaican woman with diabetes and hypertension but no renal disease initially presented for management of diverticulitis that was responsive to antibiotics and fluids. On day 4 she was evaluated by the ICU after a Rapid Response for loss of consciousness from 5 minutes of sustained VT that broke spontaneously. Electrolyte aberrations at that time showed serum calcium of 21.4mg/dL, from an initial 10.5mg/dL. The patient was started on pamidronate, calcitonin, aggressive intravenous hydration and was admitted to the ICU for closer cardiac monitoring. She was intubated for airway protection. It was determined that emergent hemodialysis was imperative to acutely lower the serum calcium. PTH was mildly suppressed in the acute phase. Vitamin D and PTHrP were marginally elevated. CT Chest ruled out granulomatous disease and sarcoidosis with a normal ACE concentration. Sestamibi scan ruled out ectopic parathyroid tissue and there was no evidence of bony metastasis on further radiologic studies. After 3 sessions of dialysis and denosumab administration, the patient’s serum calcium gradually plateaued. A bone marrow biopsy with immunophenotyping and a peripheral smear showed hypercellular marrow and lymphocytes with condensed chromatin and hyperlobulated nuclei, consistent with Acute Adult T cell Leukemia-Lymphoma (ATL). HTLV-1 was positive, which acted as a proto oncotic gene triggering her lymphoma. In light of the new diagnosis of highly aggressive NHL and poor prognosis the patient was terminally extubated per her family's wishes. DISCUSSION: Hypercalcemia of Malignancy is most often implicated in PTHrP secreting tumors like squamous cell carcinoma. ATL however has a unique manifestation of profound severe hyperacute hypercalcemia. The mechanisms are multifactorial including; secretion of pro-calcemic cytokines, marginal PTHrP production, and skeletal calcium upregulation via RANK-L expression. ATL is most often seen in the Japanese and Caribbean population where HTLV-1 infections are more prevalent. Ultimately the confluence of factors contributing to her hypercalcemia manifested as a cardiac emergency. CONCLUSIONS: There may be a role for emergent hemodialysis in severe hypercalcemia despite preserved renal function. Further, prompt oncological workup is essential to manage the underlying cause even in patients with no prior cancer history. Reference #1: Stewart, A. F. (2005). Hypercalcemia associated with cancer. New England Journal of Medicine, 352(4), 373-379. Reference #2: Sternlicht H, Glezerman IG. Hypercalcemia of malignancy and new treatment options. Therapeutics and Clinical Risk Management. 2015;11:1779-1788. DISCLOSURE: The following authors have nothing to disclose: Lokesh Dayal, Raghav Chaudhary, Hisham Hakeem, Faraz Syed No Product/Research Disclosure Information