A 67‐year‐old male with hypercalcemia and an unrevealing splenectomy

Abstract

A 67-year-old Caucasian man was admitted because of confusion and lethargy rapidly progressing over the last 3-4 weeks before presentation. He had hypertension controlled with ramipril; there was no history of alcohol use or toxic habits nor was he taking any other medications, including over-the-counter medications or herbal remedies. A weight loss of about 15 kg was reported over the last 4 months, but he did not complain of night sweats, pruritus, or fever; also, there was no family history of metabolic or malignant disease. The patient appeared unwell and lethargic, yet his vital signs were normal and the physical and neurological examination were also normal except for liver and spleen, which descended 3 cm and 4 cm, respectively, below the costal margins; no rash or palpable lymphadenopathy was detected.A wide range of disorders may explain the development of confusion and lethargy in a 67-year-old man. The differential at this early step of work-up should first dissect a metabolic disorder from a primary disorder of the central nervous system ranging from encephalitis or meningitis to cancer, lymphoma, stroke, intraparenchymal hemorrhage and subdural hematoma, seizures, and normal-pressure hydrocephalus; cerebral vasculitis is also a possibility. Most of those disorders, however, may be easily ruled out because of the absence of fever, the normal vital signs, and the normal neurological and physical examination, except for hepatosplenomegaly. Even though the patient had no history of alcohol use or toxic habits a toxicology screening was performed. Dementia, delirium, thyroid, and adrenal dysfunction, a prion-related disease or other rare disorders such as multifocal progressive leukoencephalopathy are less likely explanations. We were also concerned about his weight loss, which strongly suggested that an underlying systemic (inflammatory or neoplastic) disorder would be present.Laboratory tests showed calcium 17.2 mg/dl (normal range 8-10 mg/dl), creatinine 3.3 mg/dl (normal range 0.8-1.1 mg/dl), urea nitrogen 122 mg/dl (normal range 30-50 mg/dl), lactate dehydrogenase 1086 U/L (normal value <450 U/L), erythrocyte sedimentation rate (ESR) 120 mm/hr, C-reactive protein 15 mg/dl (normal <0.5 mg/dl), and albumin 4.1 g/dl. Hematological variables, amylase, lipase, electrolytes, coagulation, and thyroid and liver function tests were normal; arterial blood gas analysis revealed pH 7.20 with base excess 220 and normal pO2 and pCO2 when the patient was breathing room air. Urine analysis showed trace proteins, pH was 5.5, and gravity 1012; 3-4 erythrocytes and leukocytes per high-power field were observed on microscopic examination with no casts or bacteria.Such a severe hypercalcemia associated with renal dysfunction was the obvious cause of confusion and lethargy in this man. One important point is that most patients with blood calcium level of 13 mg/dl or higher have a malignant condition and multiple myeloma comes to mind first in this case because of the association of hypercalcemia with renal failure and th...