Calcium Carbonate (Tums)-Associated Milk-Alkali Syndrome as a Cause of Altered Mental Status in the Emergency Department: A Case Report

Abstract

Background: Milk-alkali syndrome (MAS) resulting in hypercalcemic crisis represents a life-threatening medical emergency in the setting of excessive calcium and absorbable alkali ingestion. While an uncommon cause of altered mental status and acute renal failure in the emergency department, emergency medicine clinicians should be aware of this syndrome due to significant morbidity and mortality if left undiagnosed. Case presentation: A 63-year-old woman with history of familial hypoparathyroidism presented to our emergency department with worsening confusion, slurred speech, generalized weakness, and failure to thrive over the course of one month. Review of systems was positive for tachypnea, polydipsia, diffuse musculoskeletal pain, dehydration, poor oral intake, nausea with nonbilious nonbloody emesis, and severe fatigue. Family reported increasing difficulties with completing activities of daily living including ambulation and medication compliance. Physical examination yielded no focal neurologic deficits concerning for ischemic stroke. Laboratory investigations revealed acute renal injury, metabolic alkalosis, and severe hypercalcemia. CT imaging of the head revealed no acute intracranial abnormalities. During evaluation, the patient revealed that she had been taking 15 calcium carbonate (tums) tablets daily, along with vitamin-D and calcitriol, as a result of increased symptoms of gastroesophageal reflux disease. The patient received aggressive fluid and subcutaneous calcitonin in the emergency department. She was admitted to the hospital, where she continued to receive aggressive intravenous fluids. Calcium supplementation was withheld and chlorthalidone discontinued. After a thorough negative workup, the etiology of her hypercalcemia was deemed most likely secondary to milk-alkali syndrome. She was discharged home in stable condition on hospital day 6 without receiving hemodialysis. Conclusions: Emergency physicians should be vigilant of MAS given the potential for high morbidity if left undiagnosed. Emergency clinicians should ask about calcium supplements, as these often won't be listed on the patient's medication list and can be purchased over the counter.