Tag Archives: Morning Report

Hypercalcemia and multiple myeloma

Today, we had an interesting case of an elderly female who presented with lethargy, constipation and generalized weakness found to have hypercalcemia. Hypercalcemia workup starts with PTH dependent vs PTH independent etiologies. 
PTH dependent hypercalcemia
  • If elveated urinary calcium, think primary hyperparathyroidism
  • If normal or low urinary calcium, think FHH
PTH independent hypercalcemia 
  • If PTHrP elevated, think cancer
  • If high 25 Vit D and high 1,25 Vit D, think excessive PO intake
  • If high 1 25 Vit D, think granulomatous disease
  • If normal, think medications, immobilization, hyperthyroidism or adrenal insufficiency

Given the hypercalcemia, protein gap, and pancytopenia, the suspicion for multiple myeloma (MM) was high. Subsequent SPEP with immunofixation and bone marrow biopsy confirmed the diagnosis of IgG kappa Multiple Myeloma. Remember that multiple myeloma is a clonal proliferation of plasma cells and bone marrow biopsy with more than 10% plasma cells confirms diagnosis. The monoclonal protein produced by these plasma cells is an abnormal immunoglobulin (immunoglobulin G [IgG], IgM, or IgA, or, rarely, IgE or IgD) and/or light chain protein (kappa or lambda), either of which causes hyperviscosity and/or end-organ damage.

Hypercalcemia and multiple myeloma Summary pdf

Hypertriglyceridemia induced acute pancreatitis

We discussed a case of a man w/ HLD, IDDM2, Obesity, hx of pancreatitis, who presented to the hospital for acute epigastric pain, decreased PO intake, and non-bloody / non-bilious emesis. He was diagnosed with Hypertriglyceridemia-induced Acute Pancreatitis.
We discussed how to approach abdominal pain as well as pearls when treating hypertriglyceridemia-induced acute pancreatitis.
Framework for abdominal pain
  • R/o emergencies: obstruction, perforation, vascular, ectopic pregnancy.

Hypertriglyceridemia-induced acute pancreatitis

  • Triglycerides are broken down into free fatty acids that accumulate to toxic levels, which can cause inflammation of the pancreas.
  • Early (within ~48 hrs) enteral refeeding is encouraged.
    • Enteral (PO) feeding is recommended over parenteral (IV) to help maintain intestinal barrier and prevent bacterial translocation from the gut.
  • Insulin is used to treat hypertriglyceridemia-induced acute pancreatitis. Insulin promotes storage of triglycerides and inhibits breakdown of triglycerides into free fatty acids.

Hypertriglyceridemia induced acute pancreatitis Summary pdf

Thyrotoxic periodic paralysis

We discussed a case of a young man who presented to the hospital for chronic, sporadic, episodic BUE and BLE weakness. He also had associated unintentional weight loss, fatigue, and body tremors. He was diagnosed with Thyrotoxic Periodic Paralysis due to Graves’ Disease.
We discussed how to approach weakness (UMN, LMN, NMJ, muscular) as well as the pathophysiology + triggers + treatment of Thyrotoxic Periodic Paralysis.
Thyrotoxic Periodic Paralysis
  • Thyrotoxic Periodic Paralysis is a channelopathy that causes intracellular shifts of potassium. Low serum potassium does not reflect a total body potassium deficit.
  • Common triggers include: high-carb meals (insulin-mediated), stress (adrenergic state), intense exercise.
  • Repletion of potassium should be gradual (~90mEq in 24 hrs) to prevent rebound hyperkalemia.

Weakness & Thyrotoxic Periodic Paralysis Summary pdf

Vasospastic angina

We discussed a case of a middle aged man presenting with acute onset chest pain and bradycardia in the setting of recurrent syncope. Our patient had negative troponins but ST elevations that met criteria for STEMI. STEMI alert was called, however repeat EKG did not meet STEMI criteria. Patient was admitted for unstable angina and received a stress test during which he experienced chest pain with EKG evidence of STEMI. Coronary angiogram was negative for coronary artery disease however he responded to intracardiac nitroglycerin with significant increase in the caliber of left PDA. He was diagnosed with a type of MINOCA (MI in the absence of obstructive CAD), known as vasospastic angina. 

It is important to think of “do not miss” chest pain differentials using the 4:2:1 method:

  • 4 cardiac for 4 chambers – ACS, Tamponade, Aortic Dissection, Myocarditis
  • 2 pulmonary for 2 lungs – Pulmonary emboli, pneumothorax
  • 1 GI tract – Esophageal rupture

Our patient had a STEMI alert called however not all ST elevations equal to STEMI. It is important to know criteria for STEMI:

  • ST segment elevation of >1mm at J in two contiguous leads other than leads V2-V3 
  • In leads V2-V3 >2mm in men older than 40yo and >2.5mm in men younger than 40 yo or >1.5mm in females