Hypercalcemia in a 67-Year-Old Female Following the Use of Calcium Sulfate Beads: A Case Report and Review of Literature

Abstract

While the milk-alkali syndrome is traditionally viewed as the sole cause of exogenous hypercalcemia, the wide use of calcium sulfate (CS) in orthopedic procedures introduced another important item to be considered in the differential diagnosis. Calcium sulfate beads are increasingly used as void fillers and prophylactic measures to prevent postoperative hardware infections. However, hypercalcemia secondary to rapid calcium absorption from calcium sulfate beads is generally an underrecognized adverse effect and likely underreported. Furthermore, with calcium sulfate beads, hypercalcemia can dramatically present with alteration in mental status. In this report, we present a case of a 67-year-old female who underwent two orthopedic procedures, where calcium sulfate beads were used in both. The patient, on both occasions, developed significant hypercalcemia, manifested as agitation and suicidal thoughts, with each episode resolving after proper hydration and lowering of serum calcium. Also, in this report, we examined the literature and highlighted the female predominance in the reported cases, often manifesting in postoperative day (POD) 4. Given the acuity and severity of hypercalcemia, it is paramount to anticipate hypercalcemia, monitor serum calcium postoperatively to allow timely interventions, and avoid potentially serious complications.

Hypercalcaemia caused by calcium sulfate beads

“…Studies of calcium sulfate bead-induced hypercalcemia are limited but data show that at least some patients will have hypercalcaemia after administration of calcium sulfate beads 2 3 8–17. Typically calcium levels peak on POD 2 and resolve around POD 10–12 16 17.…”

“…Typically calcium levels peak on POD 2 and resolve around POD 10–12 16 17. One case report involves a patient who had acute onset of undifferentiated hypercalcaemia on two separate occasions following administration of calcium-containing antibiotic beads during orthopaedic procedures 8. This suggests that there may be patient factors that predispose to hypercalcaemia after placement of calcium sulfate beads.…”

“…This suggests that there may be patient factors that predispose to hypercalcaemia after placement of calcium sulfate beads. According to a limited review, women appear to have more episodes of hypercalcaemia as nearly two out of three of available case reports involve female patients 8. Unsurprisingly, patients with factors predisposing them to disorders of calcium homeostasis (renal disease, malignancy, parathyroid disease) are more likely to develop hypercalcemia 8 17.…”

“…According to a limited review, women appear to have more episodes of hypercalcaemia as nearly two out of three of available case reports involve female patients 8. Unsurprisingly, patients with factors predisposing them to disorders of calcium homeostasis (renal disease, malignancy, parathyroid disease) are more likely to develop hypercalcemia 8 17. There may also be procedure-related factors like the volume of beads used; however, in a relatively large study of cases, this was not observed 16…”

Hypercalcemic Crisis Complicated With Acute Respiratory Distress Syndrome Due to Hot Spring Drowning: A Case Report

“…The causes of hypercalcemia include primary hyperparathyroidism, characterized by excessive parathyroid hormone (PTH) secretion, vitamin D excess, PTH-related peptide (PTHrP) production, or local bone resorption by malignant tumors [2]. Additionally, medications, prolonged bed rest, and exogenous intakes such as milk-alkali syndrome and calcium sulfate beads [3] can also be contributing factors.…”