Diseases » Hypercalcemia » Diagnosis

Diagnosis of Hypercalcemia

Diagnostic Test list for Hypercalcemia:

The list of medical tests mentioned in various sources as used in the diagnosis of Hypercalcemia includes:

• Blood calcium level tests

Hypercalcemia Diagnosis: Book Excerpts

• Ask the Following Questions - HYPERCALCEMIA
• Ask the following questions - ALKALINE PHOSPHATASE ELEVATION
• Ask the following questions - ASPARTATE AMINOTRANSFERASE ELEVATION
• Ask the Following Questions - LACTIC DEHYDROGENASE ELEVATION
• Differential Diagnosis - Hypercalcemia
• Differential Diagnosis - Hypercalcemia
• Approach to the Diagnosis - HYPERCALCEMIA
• Approach to the Diagnosis - ASPARTATE AMINOTRANSFERASE, ALANINE AMINOTRANSFERASE, AND LACTIC DEHYDROGENASE ELEVATION
• Approach to the Diagnosis - ALKALINE PHOSPHATASE ELEVATION
• Diagnosis - Calcium imbalance
• Diagnosis - Calcium imbalance
• Approach to the Diagnosis - HYPERCALCEMIA
• Approach to the Diagnosis - ALKALINE PHOSPHATASE ELEVATION

Diagnostic Tests for Hypercalcemia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Hypercalcemia.

HYPERCALCEMIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the PTH assay increased? This would point to a parathyroid tumor or hyperplasia and ectopic PTH secretion.
2. Is the alkaline phosphatase elevated? Hypercalcemia and an increased alkaline phosphatase without an increase in PTH assay suggests metastatic carcinoma of the bone, Paget's disease, and other bone tumors. Hypercalcemia without an elevated alkaline phosphatase is suggestive of multiple myeloma and hyperproteinemia due to other causes. A serum protein electrophoresis will help define this further.

DIAGNOSTIC WORKUP

A CBC, chemistry panel, 24-hr urine calcium, PTH assay, serum 25(OH) vitamin D3 , free tetraiodothyronine (thyroxine) (T ₄ ), serum protein electrophoresis, skeletal survey, bone scan, and endocrinology consult may be part of any workup of hypercalcemia.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ALKALINE PHOSPHATASE ELEVATION: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. What is the calcium level? If this is increased, one should look for primary hyperparathyroidism and bone metastasis. These two findings can be further differentiated with parathyroid hormone (PTH) assay. If calcium is decreased, the patient may have vitamin D deficiency, malabsorption syndrome, Fanconi's syndrome, or other renal diseases.
2. Are there abnormalities of liver function tests? If the calcium is normal but liver function tests are abnormal, think of liver disease, obstructive jaundice, and liver metastasis. If the patient is not pregnant, sepsis, Paget's disease, osteogenic sarcoma, gynecologic malignancies, and liver and bone metastasis may be considered.
3. What is the phosphate level? In the face of a low calcium level, a low phosphate level will help distinguish vitamin D deficiency, malabsorption syndrome, and Fanconi's syndrome from other renal diseases in which the phosphate level will be high.
4. Is there a high 5'-nucleotidase or γ -glutamyltransferase level? This will help distinguish liver disease from Paget's disease, metastatic bone disease, and osteogenic sarcoma.

DIAGNOSTIC WORKUP

The workup should include a CBC, sedimentation rate, urinalysis, chemistry panel, protein electrophoresis, liver profile, PTH assay, skeletal survey, bone scan, CT scan of the abdomen, alkaline phosphatase isoenzymes, acid phosphatase, and a PSA to rule out prostatic carcinoma.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ASPARTATE AMINOTRANSFERASE ELEVATION: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the patient receiving heparin therapy? As many as 27% of patients taking heparin have an elevated aspartate aminotransferase [AST, or serum glutamine-oxaloacetic transaminase (SGOT)], and 60% have an elevated alanine aminotransferase (ALT).
2. Are the results of liver function tests abnormal? This indicates that the elevated AST is due to liver disease.
3. Is the creatine phosphokinase (CPK) elevated? An elevated CPK would indicate that the elevated AST is related to muscle damage or disease or a myocardial infarction. Further differentiation of these two conditions is made by ordering CPK isoenzymes and an EKG.
4. What is the arm-to-tongue circulation time? This is increased in congestive heart failure.
5. Is the serum amylase elevated? This would point to pancreatitis as the cause of the AST elevation. If all of the above related tests are normal, the AST elevation is most likely due to liver disease or renal infarction.

DIAGNOSTIC WORKUP

Additional tests to order that will help pin down the diagnosis include a CBC, serum amylase, chemistry panel, lactic acid dehydrogenase (LDH) isoenzymes, γ -glutamyltransferase, urinalysis, serial EKGs, pulmonary function tests, chest x-ray, flat plate of the abdomen, electromyography (EMG), liver biopsy, and muscle biopsy. Consultation with a cardiologist or hepatologist would be prudent before ordering expensive diagnostic tests.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

LACTIC DEHYDROGENASE ELEVATION: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. What is the level of creatine phosphokinase isoenzyme containing M and B subunits (MB-CPK) ? An elevated MB-CPK combined with elevated LDH is most likely due to a myocardial infarction, although myocarditis and pericarditis can produce a similar picture.
2. What is the AST level? If the MB-CPK or CPK are not also increased, an elevation of both the LDH and AST would point to liver disease.
3. What are the serum and urine creatine levels? If these are elevated, muscle disease must be considered likely.
4. What does the lung scan show? If positive, a lung scan separates pulmonary infarction from the other conditions in this group.

DIAGNOSTIC WORKUP

The diagnostic workup should include a CBC, urinalysis, chemistry panel, sedimentation rate, ANA, urine and serum creatine, urine myoglobin, serial EKGs, blood gas analysis, LDH isoenzymes, chest x-ray, lung scan, EMG, and cardiology and neurology consults. A liver scan, CT scan of the abdomen and liver, and muscle biopsy may be necessary.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Hypercalcemia: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Primary hyperparathyroidism
  –Most commonly caused by an adenoma of one of the parathyroid glands (90% of cases of primary hyperparathyroidism)
  –Less commonly caused by parathyroid hyperplasia or carcinoma (may be associated with multiple endocrine neoplasia syndromes)
  –Symptoms may include weakness, confusion, polyuria, renal stones, nausea, and anorexia
  –Symptoms are usually only present when calcium rises over 12 mg/dL
• Drugs (e.g., thiazides, lithium)
• Malignancy (e.g., multiple myeloma, leukemia; lymphoma; breast, lung, and kidney cancers)
  –Most common cause in hospitalized patients
  –Hypercalcemia occurs due to stimulation of bone resorption by cytokines released from tumor cells or to the release of PTH-related peptide produced by the tumor
  –Symptoms are identical to primary hyperparathyroidism

• Renal failure
• Hyperthyroidism
• Addison's disease
• Familial hypocalciuric hypercalcemia
• Vitamin A or D intoxication
• Granulomatous disease (e.g., sarcoidosis, tuberculosis)
• Adrenal insufficiency
• Paget's disease
• Immobilization
• Hypophosphatemia
• Acromegaly
• Milk-alkali syndrome (due to excessive ingestion of milk or calcium supplements)

Workup and Diagnosis

• Complete history and physical examination
  –Most cases are relatively asymptomatic (fatigue and other nonspecific symptoms present)
  –“Stones, bones, abdominal groans, and psychic overtones” is the classic presentation; however, these are not common clinically

  *

  Stones: Renal stones in 50%

  *

  Bones: Bone pain, weakness, osteoporosis

  *

  Groans: Abdominal pain, nausea/vomiting, constipation, peptic ulcer disease, pancreatitis

  *

  Psychic overtones: Psychosis, depression, anxiety

  
  –Evaluate for increased urination or renal stones, GI upset, confusion, tiredness, mental status changes, hyporeflexia, hypertension, arrhythmias, and coma
• Initial laboratory studies include serum and urinary calcium, electrolytes, BUN/creatinine, parathyroid hormone, PTH-related peptide, CBC, albumin, magnesium, phosphate, alkaline phosphatase, vitamin D
  –The higher the plasma Ca²⁺, the more likely it is due to a malignancy; it is generally more difficult to correct
  –Be sure to correct calcium level for serum albumin
  –Corrected calcium level =[0.8 ×(normal albumin - serum albumin) +serum Ca^₂+]

• ECG may show ST depression, wide T waves, short ST segment, QT shortening, bradyarrhythmias, heart block
• Further lab tests and/or imaging modalities may be indicated to evaluate for specific etiologies (e.g., CT scan to rule out nephrolithiasis, amylase/lipase)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hypercalcemia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Hyperparathyroidism
  –Primary
        –Familial (MEN types 1 and 2A)
        –Familial (MEN types 1 and 2A)
        –Most common endocrinopathy in children with MEN 1
        –PTH-secreting adenoma
  –Secondary/tertiary
        –Following renal transplantation
        –Chronic hyperphosphatemia

• Familial hypocalciuric hypercalcemia (FHH)
• Vitamin D excess
  –Nutritional excess
  –Inflammatory/granulomatous diseases
        –Sarcoidosis
        –Eosinophilic granulomas
        –Tuberculosis
        –Coccidioidomycosis
        –Coccidioidomycosis
        –Lymphoma
• Immobilization
  –Bone resorption exceeds bone mineral accretion
• Malignancy
  –Neoplasms (leukemia, rhabdomyosarcoma, ovarian tumor, brain tumor)
  –Bony metastases
  –Synthesis of parathyroid-related protein (PTHrP)
  • Drugs
    –Thiazide diuretics
    –Lithium
    –Vitamin A analogs
    –Calcium supplements
    –Alkali
  • Hypophosphatemia
  • Hyperthyroidism
  • Adrenal insufficiency
  • Pheochromocytoma
  • Renal failure
  • Williams syndrome
  • Juvenile rheumatoid arthritis

  Workup and Diagnosis

  • History
    –Infant/young child: Constipation, anorexia, poor weight gain and/or poor linear growth
    –Older child/adolescent: Anorexia, nausea, vomiting, abdominal pain, dyspepsia, constipation; polyuria, polydipsia; weakness; impaired ability to concentrate, altered consciousness (irritability, confusion, depressive symptoms, lethargy)
    –All ages: Dietary intake, medications/supplements, family history of calcium disorders or neoplasms
  • Physical exam: Usually normal
  • Labs
    –Total and ionized calcium, urinary calcium excretion
    –Phosphorus
    –Intact PTH, PTHrP
    –T4, TSH
    –Complete metabolic panel
    –Vitamin D levels: 25-OH-vitamin D and 1,25-(OH)₂vitamin D
    –Evaluation of associated endocrine tumors (for MEN)
  • Studies
    –ECG: Shortened QT interval
    –Abdominal ultrasound: Nephrocalcinosis, renal calculi

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

HYPERCALCEMIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A history of neoplasm or clinical evidence of bone disease should alert one to the possibility of metastatic neoplasm. Symptoms of polyuria, polydypsia, weakness, pathologic fracture, and weight loss should suggest hyperparathyroidism. Serial calcium, phosphorus, and alkaline phosphatase levels and serum PTH assay and skeletal survey should pin down the diagnosis of hyperparathyroidism and metastatic neoplasm. A bone scan will also be helpful in identifying metastasis. A cortisone suppression test will help differentiate hyperparathyroidism from metastasis. The serum calcium will not be lowered by cortisone in hyperparathyroidism.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ASPARTATE AMINOTRANSFERASE, ALANINE AMINOTRANSFERASE, AND LACTIC DEHYDROGENASE ELEVATION: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Obviously, the first condition to rule out is myocardial infarction. This is done by ordering serial MB-CPKs (MB isoenzyme of creatine phosphokinase) and ECGs. Serum cardiac troponin levels may also be helpful. Next, determine if the patient is on heparin, because this may elevate the alanine aminotransferase (ALT) level. Various muscle diseases (dermatomyositis, muscular dystrophy, muscle trauma, etc.) may be excluded by ordering CPK enzymes also, particularly the MM (MM isoenzyme of creatine phosphokinase) fraction. Liver disease can be revealed through by a liver profile, CT scan of the abdomen, and gallbladder ultrasonography.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ALKALINE PHOSPHATASE ELEVATION: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the elevated alkaline phosphatase level is related to liver disease, the clinical examination will often show jaundice or hepatomegaly. If it is related to bone disease, the clinical examination will show bone pain, pathologic fracture, or bone mass. A liver profile will also help diagnose a liver disorder, but a CT scan of the abdomen may be necessary. A skeletal survey will usually reveal bony metastasis and other disorders of the bone, but a bone scan may be necessary to show early metastasis to the bone. A serum parathyroid hormone (PTH) level will help diagnose primary hyperparathyroidism whereas secondary hyperparathyroidism (rickets, etc.) will require the specialized tests listed below.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Calcium imbalance: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Confirming diagnosis  A serum calcium level less than 8.5 mg/dl confirms hypocalcemia; a level more than 10.5 mg/dl confirms hypercalcemia. (However, because approximately one-half of serum calcium is bound to albumin, changes in serum protein must be considered when interpreting serum calcium levels. A common conversion formula is calcium corrected = calcium actual + 0.8 x [4.0 – albumin level]. Ionized calcium levels are 4.65 to 5.28 mg/dl and are a measure of the fraction of serum calcium in ionized form.)

The Sulkowitch urine test shows increased calcium precipitation in hypercalcemia. In hypocalcemia, an electrocardiogram (ECG) reveals lengthened QT interval, prolonged ST segment, and arrhythmias; in hypercalcemia, shortened QT interval and heart block. (See Diagnosing hypercalcemia, pages  916 and 917.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Calcium imbalance: Diagnosis
(Handbook of Diseases)

A serum calcium level below 4.5 mEq/L confirms hypocalcemia; a level above 5.5 mEq/L confirms hypercalcemia. (However, because about half of serum calcium is bound to albumin, changes in serum protein must be considered when interpreting serum calcium levels.)

In patients with hypercalcemia, urine test results show an increase in urine calcium precipitation. In those with hypocalcemia, an electrocardiogram (ECG) reveals a lengthened QT interval, a prolonged ST segment, and arrhythmias; in those with hypercalcemia, an ECG reveals a shortened QT interval and heart block.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

HYPERCALCEMIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A history of neoplasm or clinical evidence of bone disease should alert one to the possibility of metastatic neoplasm. Symptoms of polyuria, polydipsia, weakness, pathologic fracture, and weight loss should suggest hyperparathyroidism. Serial calcium, phosphorus, and alkaline phosphatase levels and serum PTH assay and skeletal survey should pin down the diagnosis of hyperparathyroidism and metastatic neoplasm. A bone scan will also be helpful in identifying metastasis. A cortisone suppression test will help differentiate hyperparathyroidism from metastasis. The serum calcium will not be lowered by cortisone in hyperparathyroidism.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ALKALINE PHOSPHATASE ELEVATION: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the elevated alkaline phosphatase level is related to liver disease, the clinical examination will often show jaundice or hepatomegaly. If it is related to bone disease, the clinical examination will show bone pain, pathologic fracture, or bone mass. A liver profile will also help diagnose a liver disorder, but a CT scan of the abdomen may be necessary. A skeletal survey will usually reveal bony metastasis and other disorders of the bone, but a bone scan may be necessary to show early metastasis to the bone. A serum parathyroid hormone (PTH) level will help diagnose primary hyperparathyroidism, whereas secondary hyperparathyroidism (rickets, etc.) will require the specialized tests listed below.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Hypercalcemia

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