2. Patient Presents to ER
66 yr old white male
Complains of progressive weakness for 2
weeks
Intermittent cough, pleuritic chest pain and
exertional dyspnea for 6 days
Nausea and vomiting for 2 days PTA
What questions do you ask in history?
4. Physical Exam
appears weak
vital signs stable
oral mucosa and tongue dry
Lungs: bibasilar crackles
Cardiac: S3 gallop
What do you order?
5. Labs/X-ray
Serum Ca = 15.1
mg/dL
BUN = 65 mg/dL
Creatinine = 5.9
mg/dL
Intact PTH and 1,25
DihydroxyvitaminD
levels were normal
Serum phosphate = 4.9
mg/dL
Serum dicarbonate =
38 mmol/L
Chest x-ray showed
bilateral basilar
infiltrates
6. What is your differiential
diagnosis?
Hypercalcemia of malignancy?
Primary hyperparathyroidis?
Milk-alkali syndrome?
Immobilization?
Multiple Myeloma?
8. Milk-alkali Syndrome
Related to excessive ingestion of calcium
and absorbable antacids such as calcium
carbonate and milk
First reported in 1923
– thought to be a toxic reaction to the then
popular Sippy treatment of peptic ulcer disease.
The Sippy regimen: hourly administration of milk or
cream with a mixture of bicarbonate containing salts
that included calcium carbonate.
9. Milk-alkali Syndrome
Became rare with the advent of modern
ulcer therapy with nonabsorbable antacids,
H2 blockers and sucralfate.
May be an increased frequency of this
syndrome because of the growing
popularity of over-the-counter calcium
carbonate marketed either as antacids or as
calcium supplements for the prevention of
osteoporosis
11. Treatment Plan
Hospitalization, hydration, and diuresis
Discontinue injestion of calcium
IV Lasix and fluids
If life threatening: short course high dose
calcitonin (Calcimar) (8 IU per kg IM Q 6-
8)
Consult?
13. Prevention
Milk-alkali syndrome might easily be
prevented by restricting calcium intake to
1.2 to 1.5 g/day or by using a supplement
that does not contain absorbable alkali.
14. Recent Articles
Medline search of ‘94-present yielded 10 hits.
Brandwein SL, Sigman KM, Case report: milk-alkali
syndrome and pancreatitis., Am J Med Sci 308: 3, 173-6,
Sep, 1994.
– The relation between hypercalcemia and pancreatitis,
first described in patients with hyperparathyroidism, is
controversial. Other causes of hypercalcemia also have
been associated with pancreatitis. In this report, the
authors describe a patient with pancreatitis and the
milk-alkali syndrome who had the classic triad of
hypercalcemia, alkalosis, and renal insufficiency. The
authors also review the literature for all the reported
cases of pancreatitis associated with hypercalcemia.
15. Recent Articles
Muldowney WP, Mazbar SA, Rolaids-yogurt syndrome: a
1990s version of milk-alkali syndrome., Am J Kidney Dis
27: 2, 270-2, Feb, 1996.
Milk-alkali syndrome is characterized by progressive hypercalcemia, systemic alkalosis, and
renal insufficiency. After calcium carbonate is ingested with diary products,
hypercalcemia and alkalosis may develop in susceptible persons, particularly those with
underlying renal insufficiency. We describe a young woman who neither drank milk nor
had peptic ulcer disease, yet who ingested enough calcium carbonate to require
admission to an intensive care unit for acute renal failure. Chronically bulimic, she was
taking Rolaids (Warner-Lambert Co, Morris Plains, NJ), which contained calcium
carbonate, and was eating yogurt daily to prevent osteoporosis. We discuss the
characteristics and complex metabolic interactions of the milk-alkali syndrome, a critical
but generally reversible electrolyte disorder. Early recognition of coincident
hypercalcemia and alkalosis and prompt cessation of calcium carbonate ingestion are
essential for successful recovery. Finally, we suggest that nephrologists should
discourage patients with renal insufficiency and chronic vomiting from consuming
calcium-containing antacids and excessive dietary calcium.
16. How do you ICD9 code this?
275 Disorders of mineral metabolism
– 275.40 Disorders of calcium metabolism
hypercalcemia, calcilosis, . .
276 Disorders of fluid, electrolyte, & acid-
base balance
– 276.30 Alkalosis
NOS, respiratory, metabolic
– 276.50 Volume depletion disorder
– 276.9 Electrolyte & fluid disorders not elsewhere
classified
Editor's Notes
The milk-alkali syndrome, first reported as an adverse reaction to peptic ulcer therapy in the 1920s, may be increasing due to the growing use of calcium carbonate supplements to prevent osteoporosis.
In recent case reports of the syndrome, most patients had been taking only calcium carbonate, which provides both calcium and absorbable alkali. The pathophysiology of the syndrome remains unclear. Until the recent introduction of the immunoradiometric assay (IRMA), it was not possible to reliably distinguish the milk-alkali syndrome from
hyperparathyroidism with noninvasive studies.
Investigators reviewed the records of the 100 patients hospitalized for hypercalcemia between 1985 and 1993. Milk-alkali syndrome was diagnosed in seven of the 100 patients, based on a history of increased consumption of calcium and alkali, the presence of both hypercalcemia and metabolic acidosis, and the absence of any other explanations for these findings.
Six of the seven patients were women. All seven had been taking OTC antacids containing calcium carbonate in dosages of 4 to 12 g/day. Serum bicarbonate levels were elevated in three patients and high-normal in the rest. Serum parathyroid hormone levels, measured by IRMA in six patients at the time of admission, were low in all six.
Conservative treatment (generally saline plus loop diuretics) was associated with temporary hypocalcemia and rebound hyperparathyroidism in two patients. Renal function was significantly impaired in two patients and mildly impaired in two others.
Only one patient was admitted between 1985 and 1989; the other six were hospitalized between 1990 and 1993.
Milk-alkali syndrome accounted for 2% of all hospitalizations for hypercalcemia from 1985 to 1990 and 12% of such admissions between 1990 and 1993, a statistically significant increase.
Use of OTC medications and dairy products should be carefully investigated in all hypercalcemic patients.
Determination of serum parathyroid levels with IRMA can reliably distinguish milk-alkali syndrome from hyperparathyroidism. However, the assay should be performed shortly after admission because treatment often leads to a rapid rebound of parathyroid hormone levels.
Milk-alkali syndrome might easily be prevented by restricting calcium intake to 1.2 to 1.5 g/day or by using a supplement that does not contain absorbable alkali.
SOURCE: Beall, D., and Scofield, R. Milk-alkali syndrome associated with calcium carbonate
consumption. Medicine 74:89-96, Mar. 1995. From the University of Oklahoma Health Science
Center, Oklahoma City; and other institutions. Source of funding not stated.
Medline search of milk-alkali syndrome in 1994-present yielded 10 articles.