A 54-year-old man comes to the emergency department due to a cough. He has a 44-pack-year smoking history but quit a month ago. The patient has also experienced weight loss, anorexia, constipation, increased thirst, and fatigue, which he attributes to depression. He lost his wife to breast cancer 4 months ago and says that "life hasn't felt the same since then." Blood pressure is 104/68 mm Hg, pulse is 95/min, and respirations are 24/min. Oxygen saturation is 92% on room air. The patient appears thin, pale, and short of breath. Laboratory results are as follows: Chest x-ray reveals a hilar mass in the left lung. What is the best next step in management of this patient?

Question

A 54-year-old man comes to the emergency department due to a cough.  He has a 44-pack-year smoking history but quit a month ago.  The patient has also experienced weight loss, anorexia, constipation, increased thirst, and fatigue, which he attributes to depression.  He lost his wife to breast cancer 4 months ago and says that "life hasn't felt the same since then."  Blood pressure is 104/68 mm Hg, pulse is 95/min, and respirations are 24/min.  Oxygen saturation is 92% on room air.  The patient appears thin, pale, and short of breath.  Laboratory results are as follows:  Chest x-ray reveals a hilar mass in the left lung.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d4e0_9ed4_bc81_47a1d0f68962_MD0003_00 This patient has severe symptomatic hypercalcemia. In light of his smoking history and associated lung mass, this likely represents humoral hypercalcemia of malignancy due to secretion of parathyroid hormone-related protein. Severe hypercalcemia (serum calcium >14 mg/dL), especially with a rapid rise in serum calcium, can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms (eg, confusion, stupor, coma). Patients are typically volume depleted (as suggested by this patient's blood urea nitrogen to creatinine ratio >20) due to both polyuria from hypercalcemia-induced nephrogenic diabetes insipidus and decreased oral intake. Patients with severe hypercalcemia require aggressive saline hydration (ie, several liters of normal saline) to restore intravascular volume and promote urinary calcium excretion. Calcitonin, by inhibiting osteoclast-mediated bone resorption, quickly reduces serum calcium concentrations and may be administered concurrently with saline. Bisphosphonates (eg, pamidronate, zoledronic acid) also inhibit bone resorption and provide a sustained reduction in calcium levels. However, the calcium-lowering effect of bisphosphonates is delayed, usually occurring over 2-4 days, and they are typically given after initial administration of saline and calcitonin. (Choice A) This patient may have metastatic carcinoma of the lung, which warrants additional imaging. However, the hypercalcemia and hypovolemia must be corrected urgently, especially before administration of radiographic contrast agents. (Choice B) Hemodialysis is an effective treatment for hypercalcemia. However, it is typically reserved for patients with renal insufficiency or heart failure in whom aggressive hydration cannot be administered safely. (Choice C) Glucocorticoids inhibit the formation of 1,25-dihydroxyvitamin D by activated mononuclear cells in the lungs and lymph nodes. Glucocorticoids can be used to treat hypercalcemia due to excessive vitamin D intake, granulomatous diseases (eg, sarcoidosis), and certain lymphomas. However, most cases of malignancy-related hypercalcemia are not due to vitamin D excess. (Choice D) Although loop diuretics can promote diuresis and reduce calcium levels, their routine use in hypercalcemic patients is not recommended as they can worsen the volume depletion. Educational objective: Severe hypercalcemia can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms. Patients are typically volume depleted due to polyuria and decreased oral intake. Initial treatment includes saline hydration to restore intravascular volume and calcitonin to inhibit bone resorption. Bisphosphonates further reduce calcium levels and are given after initial administration of saline. References: Treatment of acute hypercalcemia. (http://www.ncbi.nlm.nih.gov/pubmed/22571195)

A 54-Year-Old Man Comes to the Emergency Department Due to a Cough