Hal is a 73-year-old patient with refractory multiple myeloma. Florence, his wife, calls the hematologist’s office and asks to speak with the triage nurse. She says she is worried about her husband and that “he’s just not himself.” He is considerably more tired, is unsteady on his feet, has had some hallucinations, and is confused. She tried cutting back on his pain medication, but the problems have only gotten worse. She adds that today he has had urinary incontinence.

What Would You Do?

Upon reviewing Hal’s chart, the nurse notes that Hal was initially diagnosed five years ago but has not received active treatment since failing salvage therapy several months ago. His prescription for hydrocodone had not been renewed for quite some time. Lab work reveals renal insufficiency, although his creatinine has been stable. Of interest, Hal’s last calcium level six weeks ago was 9.9 mg/dl. He was scheduled for another draw last week but never came in for the appointment.

Hypercalcemia of malignancy occurs in almost 30% of patients with cancer and is associated with multiple myeloma, breast cancer, and squamous cell lung cancer. Local osteolytic calcemia, frequently associated with multiple myeloma, is caused by increased bone resporption. A number of cytokines have been implicated, including interleukin-1 and -6, TGF-alpha, and TNF-alpha and -beta. This results in an imbalance in the complex osteoblast-osteoclast system, which causes bone loss and hypercalcemia.

Signs and symptoms can be difficult to detect as they may emerge gradually over time. However, symptoms can escalate with rapid increases in serum calcium levels. There is also a relationship between renal impairment and hypercalcemia, as the latter can both cause and be exacerbated by the former. In addition to the symptoms described by Florence, hypercalcemia of malignancy can result in cardiac events and seizures.

Recognizing that Hal’s symptoms could be caused by hypercalcemia, the nurse instructed Florence to have him brought to the hospital for immediate evaluation.