Dialysis is used for patients who have failed all medical therapy, are anuric, or have a calcium level > 18 mg/dL in the context of severe neurologic symptoms. For the patient in this case, dialysis was the only therapy that both reduced calcium levels substantially and led to meaningful clinical improvement.
This patient did not receive dialysis until day 4 of her hospital stay. Earlier dialysis may have been indicated; however, her concomitant sepsis and pulmonary embolism may have distracted from the prompt treatment of hypercalcemia.
In conclusion, always keep hypercalcemia in the differential diagnosis for a patient who presents with confusion and altered mental status. Make sure to account for the albumin level and order an ionized calcium level. Start with medical therapy with the understanding that sometimes dialysis is not only warranted but the only treatment that will rapidly improve symptomatic hypercalcemia.
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Cite this: Danny Gersowsky. Internal Medicine Case Challenge: Hallucinations, Moaning, and Confusion in an 88-Year-Old - Medscape - May 10, 2023.