SEVERE HYPERCALCAEMIA OF HYPERPARATHYROIDISM WITH CARDIAC COMPROMISE

AVOIDING DIALYSIS WITH AGGRESSIVE MEDICAL THERAPY

Abstract

INTRODUCTION
Severe hypercalcaemia of primary hyperparathyroidism (pHPT) is usually symptomatic and carries high mortality risk due to cardiac arrhythmia and decompensation. Treatment involves vigorous hydration alongside anti-resorptive agents such as bisphosphonate and RANK-Ligand inhibitor i.e., denosumab. Usually, serum calcium of more than 4 mmol/l necessitates dialysis. Here, we report a case of severe hypercalcaemia of hyperparathyroidism with cardiac compromise treated medically resulting to avoidance of dialysis.

CASE
The case is a 50-year-old female with hypertension and chronic kidney disease stage IIIB who was diagnosed with primary hyperparathyroidism since 2020. She was stable with mild hypercalcaemia (calcium less than 3.0 mmol/L). During endocrine follow-up, she complained of constipation, abdominal discomfort, lethargy and vomiting for 2 weeks. She has no cough, no constitutional symptoms, no bone pain, no recent fracture or immobilisation and she denied taking any supplementations. Clinical assessment done was in keeping with severe dehydration.

Blood investigations revealed severe hypercalcaemia (5.01 mmol/L) with normal phosphate and acute azotemia (urea 11, Creatinine 191). Electrocardiography showed first degree heart block, with short QT interval, and a heart rate 60-80 bpm.

Hydration with 5 litres of normal saline and intravenous denosumab was given. Nephrology team was consulted, but no dialysis was planned. On the third day of admission, hydration was increased to 6 litres/day alongside intravenous furosemide to induce forced diuresis. Calcium level reduced to 3.1 mmol/L after a week of admission. Repeated ECG showed resolution of the heart block and short QT. Right inferior parathyroidectomy was done after localisation 2 weeks after. Histopathology confirmed parathyroid adenoma.

CONCLUSION
Severe hypercalcaemia of pHPT can be successfully managed with aggressive treatment and close monitoring . Need for dialysis may be avoided but such patients should undergo parathyroidectomy as soon as possible