A 70 year old male referred by GP to ED with a 4 week history of general decline. He has been complaining of mid thoracic back pain and has been intermittently confused. He has a background history of hypertension and is a smoker.
The above blood results show a pancytopaenia with a normocytic anaemia, moderately low platelets and lymphopaenia with a neutropaenia of 0.6. The biochem shows mild renal impairment, with normal sodium and potassium, and a severely raised calcium of 3.86 mmol/l.
Pancytopaenia can be caused by marrow infiltration (malignant and non malignant causes), marrow failure (immune suppression/destruction, nutritional, marrow suppression), or destruction/sequestration (consumption -DIC/splenomegaly). In the presence of such high calcium the likely cause would be malignancy.
Causes of hypercalcemia that are related to malignancy (lung, breast, and myeloma are the most common tumors) include the following:
- Solid tumor mets
- Solid tumor with humoral effect
- Haematological malignancies
Further investigation of this patient would require:
- Lab studies – blood smear, retic count, coagulation profile, LDH, uric acid and LFT
- ECG
- CXR
- Thoracic spine Xrays
- Further investigation looking for source of infection and possible bleeding
- Further investigations needed as inpatient – bone scanning, urine and serum electrophoresis looking for malignancy
Treatment of this patient in ED would include
- Specific management of hypercalcaemia – volume replacement at 200-300ml/hr aiming for urine output of 100 -150ml/hr, calcitonin, bisphosphonates – pamidronate. Loop diuretics should be avoided unless underlying CCF. Avoid calcium containing food and medication
- Look for and treat any underlying infection or bleeding
- Admission for further work up and haemotology consult.