CALCIUM SEMINAR

CLINICAL AND BIOCHEMICAL APPROACH TO PATIENTS

WITH CALCIUM DISORDERS

CASE #1

A 60-year-old female sustains a forearm (radius) fracture after falling from a

standing height. She also reports having passed a small kidney stone 1 year ago.
Physical exam reveals a healthy appearing woman with a BMI of 23, dry oral
mucosa, good muscle mass, and normal spinal curvature. Lab tests show a
calcium of 11.7 mg/dl (normal, 8.5 - 10.4), a low serum phosphorus, serum
creatinine 1.5 mg/dL (normal 0.6 – 1.4), Intact parathyroid hormone (PTH) is 190
pg/ml (normal 10 - 65), urinalysis with calcium oxalate crystals, and an elevated
alkaline phosphatase.

1. What disease does this patient have? What diseases are associated with a
high PTH? What are some hypercalcemic disorders that are associated with a
suppressed PTH? What hypercalcemic disorders are associated with an
"inappropriately" normal PTH? What should you think of in person with a high PTH
and a normal serum calcium?

2. Based on your diagnosis, explain each of the following: fracture and

elevated alkaline phosphatase, kidney stone, low phosphorus, abnormal
renal function, and dry oral mucosa.

3. What would this patient's bone biopsy show? What is "osteoid"? Which
disorders are associated with increased osteoid?
CASE #2

A 53-year -old man comes to see you because of generalized achiness and pain in his left lateral ribs.
The achiness is been present for three months; the rib pain began after he rolled over in bed (two
days prior to his visit). He has been in good health although is felt weak and cold over the last month
and has noticed a greater frequency of respiratory infections recently. He has no known medical
problems. He is on no medication. His physical exam is unremarkable except for very pale mucous
membranes and tenderness over his left lateral ribs. His lab dated show an anemia, a low albumin of
2.5 g (normal, 3.5 – 5), normal renal function, a normal serum calcium of 10.2 MG/DL (normal, 8.5 –
10.4), an ionized calcium of 6 MG/DL (normal, 4.5 – 5.5), a parathyroid hormone level which is
suppressed below normal, a monoclonal protein with suppression of the other globulins and a normal
bone alkaline phosphatase.

1. Why is there a difference between the ionized calcium and the total
calcium? How can you "correct" the reported total serum calcium?

2. What is the cause of the elevated calcium in this patient? What are some
mechanisms by which tumors can cause hypercalcemia?

3. Why is the patient’s parathyroid hormone suppressed?

4. Why is the bone alkaline phosphatase normal?

 OSTEOPOROSIS AND METABOLIC BONE DISEASE SEMINAR

CASE #l
A 60 year old woman sees you because she is concerned about osteoporosis. Her
mother who is now 85 years old recently fractured her hip and has a Dowager's
hump (severe kyphosis). The patient is 9 years post-menopause (Last menstrual
period at age 51). She has no history of fracture. She has lost 1 cm of height.

1. What is osteoporosis? What is high turnover osteoporosis? What is

low turnover osteoporosis? Which type of bone turnover is your 52
year old patient more likely to have?

2. How is the bone density measured? What anatomic sites are measured?
What is the T-score? What is the Z-score?

What scores suggest "osteopenia" (low bone mass)? What scores

suggest "osteoporosis" (higher risk of fracture)?

What results suggest that the patient might have a disease other than
age related / post-menopausal osteoporosis?

3. What factors, other than bone density, predict whether this patient is likely to
sustain a fragility fracture (a low impact fracture from a standing height)?
CASE #2

A 47-year-old woman sees you after breaking three of her ribs while coughing during a
week long bout of viral bronchitis.

Her first menstrual period was at age 12. She is still menstruating regularly. She has
had three children. She has been lean her entire life, but has never had an eating
disorder. She has a longstanding history of lactose intolerance and does not
consume any milk. She has a family history of skin cancer and avoids sunlight and
wears sunscreen.

She has recently felt an increase in fatigue and friends have noticed that she
looks pale. She has also experienced some abdominal bloating and intermittent
diarrhea over the last 6 months. Her mother has no history of fracture or
becoming round shouldered.

She has never smoked. She drinks one glass of wine a day. She drinks two cups of
coffee a day. She walks approximately one mile daily and does light weight training
2 days per week.

Physical examination reveals a lean woman, weight = 110 lbs, BMI =20, pale
conjunctiva, tenderness over her left ribs, good muscle tone and strength in her
extremities.

The patient's blood chemistries and urine testing

reveal:
• serum calcium is 8.4 mg/dl (normal 8.5 -10)
• serum phosphorus is 2.3 mg/dl (normal 2.4 -4.5)
• 24 hour urine calcium is 5 mg/24hrs
(normal 50 -250)
• normal renal function
• normal albumin and normal calculated globulin level
• hemoglobin is 10 gms, and her MCV is 105 (anemia with large
red cells). B12 and folate levels are very low.

Bone density (DXA) shows:

T-score Z-score
Lumbar spine -3.0 -2.0
Femoral neck -3.5 -2.5
Forearm (113 radius) -4.0 -3.0

QUESTIONS:

1. What bone disorder does this patient have? Explain how you came to this
conclusion. What diseases cause this disorder? Which diagnoses are likely
in this patient?

2. What is the likely result of each one of the following tests (elevated,
normal or low)? Explain the reasoning behind your answers.
 a. 25-hydroxy Vitamin D
b. 1,25-hydroxy Vitamin D
c. Intact parathyroid hormone (PTH)
d. Bone alkaline phosphatase
e. N-terminal telopeptide (a measure of bone collagen breakdown)

3. What would a bone biopsy show?

4. How would you treat this patient?