Hypercalcaemia caused by calcium sulfate beads

Abstract

Hypercalcaemia is a relatively common metabolic disturbance seen in hospitalised patients; however, given the complicated systems of calcium regulation, it can take a significant amount of time and testing to pinpoint the aetiology. This case discusses a patient who developed acute hypercalcaemia from calcium sulfate-containing antibiotic beads placed during an orthopaedic procedure. These beads are used in surgical procedures to fill gaps/voids in bony structures and for local delivery of antibiotics. The case highlights the importance of careful review of a patient’s hospital course, including the administration of medical products that may not be clearly documented on a patient’s medicine administration record when working up an unexplained finding.

Limitations and modifications in the clinical application of calcium sulfate

“…A recent study by Jiang et al ( 94 ) investigated the relationship between the incidence of hypercalcemia and the dosage of calcium sulfate in patients who received local CS implantation for the management of posttraumatic osteomyelitis and found that none of the patients had hypercalcemia, and no significant links were identified between CS volume and postoperative calcium levels. In another recent case report, Vora et al ( 88 ) demonstrated that the volume of CS placed was not related to hypercalcemia. To date, there is no evidence that a large amount of calcium sulfate can increase the risk of transient hypercalcemia.…”

“…Hypercalcemia resulting from calcium sulfate is a rare but severe side effect, and alterations in mental status are the most common clinical symptoms. In addition, a few patients may have renal failure or acute encephalopathy secondary to hypercalcemia or antibiotic toxicity ( 88 , 89 ). Hypercalcemia was first described in a canine model, but elevated serum calcium levels were not sustained, and no symptoms were noted in the 1950s ( 41 ).…”

“…In 2005, the FDA warned that calcium sulfate may cause hypercalcemia based on an adverse reaction report about transient hypercalcemia following the placement of vancomycin-infused CSBs in a patient undergoing hip arthroplasty ( 90 ). However, it was not until 2015 that the first clinical case of hypercalcemia following the use of absorbable calcium sulfate in hip arthroplasty was reported and published by Carlson et al ( 88 ). Another study in the same year by Kallala et al ( 91 ) demonstrated that 3 of 15 patients with a periprosthetic joint infection developed hypercalcemia, with 1 patient developing symptoms of altered mental status, who received CS-containing antibiotics in revision arthroplasty.…”

“…It can promote bone regeneration, that is, improve the mechanical stability of bone. The second is that a local drop in pH during calcium sulfate dissolution causes surface demineralization of the surrounding bone and subsequent exposure of growth factors such as transforming growth factors and bone morphogenetic proteins, thus stimulating new bone formation ( 88 , 99 ). In addition, mechanical stability is also necessary in the process of bone healing ( 24 ).…”