Internal Medicine Case Challenge: Hallucinations, Moaning, and Confusion in an 88-Year-Old

Danny Gersowsky, DO


May 10, 2023

The next morning, the patient's calcium level was 12.8 mg/dL, and her condition had improved clinically. She was more arousable, was no longer moaning or having hallucinations, and was alert and oriented to person and place. Given this dramatic clinical improvement, another session of hemodialysis was ordered. Her calcium level decreased to 11.3 mg/dL, and her condition continued to improve clinically.

The patient subsequently underwent a successful parathyroidectomy. On the first day after surgery, her calcium level was 9.8 mg/dL, and her parathyroid hormone level was 79 pg/mL. She was fully alert and oriented and had returned to her baseline mental status. The patient was then discharged from the ICU.

Hypercalcemia is a potentially fatal cause of confusion and altered mental status that emergency physicians need to be aware of.[1] About 98% of the body's calcium is in the bones, with only 2% in the blood; of the 2% in the blood, half of it is free (ionized) and half is bound to albumin.[2] Thus, the serum calcium level represents the total of both ionized calcium and calcium bound to albumin. However, only ionized calcium is biologically active. It is important to keep this in mind because low levels of albumin can falsely lower serum calcium levels.[1,2,3]

Calcium levels > 10.5 mg/dL are considered high, levels > 12 mg/dL are considered very high, and levels > 14 mg/dL are considered severe. According to some studies, close to 80% of calcium levels > 12 mg/dL that are encountered in the emergency department are associated with cancer. It is also important to consider that symptoms of hypercalcemia correlate more closely with the rate of rise of calcium, not the level.[2,3,4] The most common symptoms are known by the mnemonic stones, bones, groans, moans, thrones, psychic overtones. Stones refer to renal calculi, bones to bone pain, groans to dehydration, moans to abdominal pain, thrones to renal insufficiency, and psychic overtones to hallucinations. The patient in this case appears to have almost all these symptoms except for renal calculi.

Saline hydration is the initial standard of care for the treatment of hypercalcemia except when it is severe (calcium level > 14 mg/dL).[1,2] For severe hypercalcemia, medication options include calcitonin, bisphosphonates, and cinacalcet. However, saline hydration remains the initial treatment of choice. Calcitonin is usually given as 3-4 IU/kg subcutaneously or intravenously and should lower calcium levels within 2-4 hours. Bisphosphonates, which include pamidronate 90 mg intravenously and zoledronate 4 mg intravenously, typically lower calcium levels within 12-14 hours. Bisphosphonates should not be used in patients with renal failure.[2,3,4] Thus, the patient in this case did not receive bisphosphonates. Cinacalcet is rarely used, and no clear dose has been established. The recommendation is to dose according to the discretion of the nephrologist.[2,3,6] In the patient in this case, saline hydration, calcitonin, and cinacalcet were all used unsuccessfully.


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