Chronic metabolic acidosis increases alkali mobilization from the bone and promotes the development of osteoporosis. We report the case of a 35-year-old Caucasian female who presented for surgical fixation of a left femoral fracture sustained six months previously from a ground level fall with known primary hypothyroidism (for 12 years, on thyroxine replacement) with history of hypokalemia for the last 13 years (on regular oral potassium supplements). There was no history of fracture in past. There was no history of renal stones. There was positive history of hypokalemic periodic paralysis twice in past (12 and 13 years back). There was no history of recurrent oral or ocular ulcers. On examination there was no uveitis, oral ulcers, lacrimal or parotid gland enlargement. Upon workup the patient was diagnosed with left-sided femur fracture (neck) and was admitted for surgical management. She underwent left dynamic hip screw fixation under general anesthesia which she tolerated well. Upon further workup she had normal anion gap with hyperchloremic metabolic acidosis, low vitamin D level and dual-energy x-ray absorptiometry (DEXA) scan revealed osteoporosis at femur and hip joint. Vitamin D was replaced, she was started on Ibandronate and calcium supplements. Her further workup revealed positive anti-SSA. Our final clinical diagnosis in this case is possible or incomplete Sjogren's syndrome causing type-1 renal tubular acidosis (RTA; distal RTA) with osteoporosis.
Background: Hypercalcemia is a common electrolyte abnormality presenting with a variety of symptoms. The common causes are primary hyperparathyroidism and malignancy associated with hypercalcemia. However, iatrogenic hypercalcemia with the overzealous use of vitamin D has now emerged as another important cause of hypercalcemia over the past decade.Objective: This study aims to evaluate the causes of hypercalcemia, management strategies, and outcomes in patients admitted with hypercalcemia in a tertiary care hospital.Method: It is a retrospective study done at Aga Khan University Hospital (AKUH), Karachi after taking approval from the ethical review committee (ERC). Data were gathered about all patients admitted from 1st January 2008 to 31st December 2018. A total of 1142 patients were included in the study and their calcium levels were noted. Along with demographic details, data pertaining to their diagnosis and all investigations done to evaluate the causes of hypercalcemia were noted in a pre-defined questionnaire.Results: A total of 814 patients having hypercalcemia were included in the final analysis and their mean age was 60.8 ± 14.1 years. Male and female patients were 45.4% and 54.6%, respectively, and their mean hospital stay was 6.2 ± 5.8 days. The most common cause of hypercalcemia was malignant solid tumors (49.1%), followed by hematological malignancy (16.5%), hyperparathyroidism (10.9%), definite vitamin D toxicity (8%), chronic kidney disease (4.9%), chronic granulomatous diseases (4.7%), and probable vitamin D toxicity (3.5%). The oral cavity carcinoma (17.7%) was the most common solid tumor associated with hypercalcemia. Amongst hematological malignancy, multiple myeloma (14.4%) was the most common one. Out of 814 patients admitted with hypercalcemia, 601 (74%) patients recovered from hypercalcemia, while mortality was observed in 129 (16%) patients. Of those who expired, 110 (85.3%) had malignancy either solid tumor or hematological.Conclusion: Malignancy is the most common cause of hypercalcemia in admitted patients. The knowledge of hypercalcemia's causes is of great importance so that targeted investigations can be done. Not only will it minimize the cost burden and shorten the hospitalization of patients; it will also help the physicians to decide the appropriate management accordingly. Moreover, vitamin D toxicity was also observed in a significant number of patients which highlights the common practice of using higher doses of vitamin D by physicians.
Brown tumour is an infrequent, focal, and benign osteolytic lesion which is a consequence of abnormal bone metabolism in hyperparathyroidism (both primary and secondary). It is also known as Osteoclastoma. In the present era, we rarely encounter skeletal disease caused by primary hyperparathyroidism. Although it is a rare presentation because of advancement of treatment but still can be encountered because of lack of standard care so we should have high index of suspicion to avoid this preventable complication. We report here a case of brown tumour in the thoracic vertebra of a young female patient with End Stage Renal Disease, who presented with backache and bilateral lower limb weakness. MRI of the spine showed multiple non-enhancing abnormal signals involving vertebral body of C2, posterior elements of C6, and bilateral sacral vertebra, suggestive of healed fractures versus bone forming tumours. She underwent laminectomy. ---Continue
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