SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Hypercalcemic crisis is a rare, life-threatening event secondary to decompensated hypercalcemia leading to renal failure and altered mental status. Primary hyperparathyroidism and hypercalcemia of malignancy are the majority of cases. However, hypercalcemia resulting from increased consumption of calcium supplement as part of the calcium-alkali syndrome should be considered. CASE PRESENTATION: An 88-year-old male presented to the ED with a history of increased confusion for 2 days. His past medical history was significant for chronic kidney disease stage 3. There was no family history of kidney stone disease, hyperparathyroidism or hypercalcemia. Vital signs were stable. Physical examination was remarkable only for dry oral mucosa and confusion. His medications did not include diuretics. His wife reported that he had been taking 10-12 tablets daily of Tums (calcium carbonate 1000mg/tablet, equivalent to 400mg of elemental calcium/tablet) recently due to worsening acid reflux. Initial electrolytes revealed serum total calcium 15.2 mg/dL, BUN 80 mg/dL, Creatinine 8.2 mg/dL, and bicarbonate 33 mmol/L. The parathyroid hormone-related peptide and 25(OH)D were normal. He had normal liver function tests, thyroid function test, Prostate-Specific Antigen, and hemoglobin. Multiple myeloma was ruled out based on normal serum and urine immunofixation studies. Electrocardiogram showed sinus bradycardia with normal corrected QT interval. A CT scan of the brain revealed no evidence of stroke. Renal ultrasound showed no renal stones or hydronephrosis. Chest x-ray did not show evidence of mass or lymphadenopathy. Hypercalcemia and renal failure failed to improve despite medical management with intravenous fluids and Calcitonin. The next day the patient received one session of hemodialysis. There was a gradual improvement in the patient’s mental status, calcium level, and renal function over the next week. DISCUSSION: The diagnosis of calcium-alkali syndrome is made based on history and metabolic abnormalities. The classic triad consists of hypercalcemia, varying degrees of renal failure, and metabolic alkalosis. The clinical presentation varies depending upon the severity of hypercalcemia. Patients may be relatively asymptomatic or may present with symptoms of nausea, vomiting, and altered mental status. In asymptomatic patients, initial management with aggressive hydration and induced diuresis with either calcitonin or bisphosphonates is recommended. However, in symptomatic or failed medical management patients, one session of hemodialysis to reduce hypercalcemia is recommended. Patients should have a close serial follow-up to rule out occult malignancy for the next 6 months. CONCLUSIONS: Due to the increasing use of calcium carbonate for dyspepsia and osteoporosis, patients should be educated and made aware of these severe, potentially life-threatening adverse effects. Reference #1: Ziegler R. Hypercalcemic crisis. J Am Soc Nephrol 2001; 12 (Suppl 17): S3–S9 Reference #2: Patel AM, Goldfarb S. Got calcium? Welcome to the calcium- alkali syndrome. J Am Soc Nephrol 2010; 21: 1440–1443 DISCLOSURES: No relevant relationships by Meily Arevalo, source=Web Response No relevant relationships by Cinthya Carrasco Barcenas, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Myrian Vinan Vega, source=Web Response No relevant relationships by Wasawat Vutthikraivit, source=Web Response