Milk-Alkali Syndrome as a Cause of Hypercalcemia in a Gentleman With Acute Kidney Injury and Excessive Antacid Intake

Abstract

Among the pertinent differentials for hypercalcemia, milk-alkali syndrome remains a diagnosis of exclusion following a thorough workup of other severe causes. However, several key signs may increase a clinician's index of suspicion for possible milk-alkali syndrome, including a prolonged history of antacid ingestion. Milk-alkali syndrome commonly presents with a classic triad: hypercalcemia, metabolic alkalosis, and acute kidney injury. The diagnostic workup should include evaluation of both serum and urine calcium levels, serum phosphate levels, and other hormones (parathyroid hormone, vitamin D). In the case of a confirmed diagnosis of milk-alkali syndrome, rapid correction of calcium levels is of utmost importance. We present the case and workup of an individual presenting to the emergency room with hypercalcemia, acute kidney injury, and several key systemic symptoms. Given a significant history of antacid overuse, and a thorough diagnostic workup, a diagnosis of milk-alkali syndrome was made and the patient was treated accordingly, making a full recovery. We review this rare case and important clinical pearls regarding milk-alkali syndrome.

A Case of Milk-Alkali Syndrome

“…With the introduction of new drugs for peptic ulcer treatment such as H2 receptor blockers, the syndrome vanished. There has, however, been an increased number of cases in recent times due to the common use of over-the-counter preparations of calcium for the prevention of osteoporosis in postmenopausal women [1,5]. Calcium carbonate is also frequently prescribed in patients with chronic kidney disease, for peptic ulcer disease, or the prevention of secondary hyperparathyroidism [1].…”

“…There has, however, been an increased number of cases in recent times due to the common use of over-the-counter preparations of calcium for the prevention of osteoporosis in postmenopausal women [1,5]. Calcium carbonate is also frequently prescribed in patients with chronic kidney disease, for peptic ulcer disease, or the prevention of secondary hyperparathyroidism [1]. Similarly, our patient is postmenopausal and was on calcium carbonate for acid reflux and an over-thecounter calcium supplement before developing this syndrome.…”

“…Characterized by the triad of elevated levels of calcium, metabolic alkalosis, and acute kidney injury, milkalkali syndrome commonly occurs due to the combined intake of large amounts of calcium and absorbable alkali [1]. Historically, this syndrome was commonly seen when Dr. Bertram Sippy introduced peptic ulcer disease treatment consisting of milk and cream combined with absorbable alkali [1,2]. With the advent of modern histamine (H2)-antagonists and proton pump inhibitor (PPI) treatment for peptic ulcer disease, this syndrome virtually vanished [1].…”

“…Historically, this syndrome was commonly seen when Dr. Bertram Sippy introduced peptic ulcer disease treatment consisting of milk and cream combined with absorbable alkali [1,2]. With the advent of modern histamine (H2)-antagonists and proton pump inhibitor (PPI) treatment for peptic ulcer disease, this syndrome virtually vanished [1]. Recently, however, an increased number of cases of milk-alkali syndrome have been reported.…”

“…Recently, however, an increased number of cases of milk-alkali syndrome have been reported. This is likely due to the common use of over-the-counter calcium preparations for preventing and treating osteoporosis in postmenopausal women [1]. Milk-alkali syndrome is becoming a more frequent cause of hypercalcemia.…”