Rehan Mehboob A, Rashid Asma, Krell Kenneth, Gabutti Cristina, Singh Reema
Department of Medicine, Eastern Idaho Regional Medical Center, Idaho Falls, USA.
Department of Critical Care Medicine, Eastern Idaho Regional Medical Center, Idaho Falls, USA.
Cureus. 2020 Oct 8;12(10):e10856. doi: 10.7759/cureus.10856.
Depending on each institution's laboratory test, mean serum calcium levels range between 8.8 and 10.8 mg/dL and hypercalcemia is defined as two standard deviations above the mean. According to recent epidemiological studies, 90% of cases of hypercalcemia are due to hyperparathyroidism or malignancy. Milk Alkali syndrome (MAS) also known as Calcium Alkali syndrome (CAS) is the third biggest cause of hypercalcemia, but its incidence seems to be higher than previously thought. Here we present a case of Calcium Alkali Thiazide syndrome (CATS) in a 57-year-old female who was on calcium and vitamin D supplements (after parathyroidectomy) while also taking thiazide diuretic for hypertension. She was brought to the ED with nausea, vomiting, confusion, difficulty walking along with numbness in extremities. She had parathyroidectomy three weeks ago. During history taking, patient reported intake of calcium carbonate 1 g three times daily, calcitriol 0.5 mcg twice daily, cholecalciferol (vitamin D3) 10,000 units once daily, chlorthalidone 25 mg once daily and irbesartan 300 mg once daily. At admission, her calcium level was 23 mg/dL, ionized calcium 12.03 mg/dL, pH was 7.59 and HCO3 was 33. She was in renal failure with creatinine of 1.9 mg/dL (baseline 0.8 mg/dL). Her parathyroid hormone (PTH) level was 0. A diagnosis of CATS was made. She was treated with intravenous fluids and furosemide and discharged home on hospital day 5 after her calcium and creatinine levels normalized. A triad of hypercalcemia, acute kidney injury and metabolic alkalosis comprises MAS. Traditional MAS was caused by "Sippy diet" (containing milk and alkali) used for the treatment of peptic ulcer disease. Over the decades, the same triad of symptoms occurred in patients using excess calcium and vitamin D, hence changing the name to CAS. A subset of patients at risk for CAS also use thiazide diuretics for hypertension, making them more vulnerable to hypercalcemia and acute kidney injury. In such subset of patients, it is preferable to use the term CATS rather than MAS or CAS.
根据各机构的实验室检测结果，血清钙平均水平在8.8至10.8毫克/分升之间，血钙过高被定义为高于平均水平两个标准差。根据最近的流行病学研究，90%的血钙过高病例是由甲状旁腺功能亢进或恶性肿瘤引起的。乳碱综合征（MAS），也称为钙碱综合征（CAS），是血钙过高的第三大原因，但其发病率似乎比之前认为的要高。在此，我们报告一例57岁女性的钙碱噻嗪综合征（CATS）病例，该患者在甲状旁腺切除术后服用钙和维生素D补充剂，同时因高血压服用噻嗪类利尿剂。她因恶心、呕吐、意识模糊、行走困难以及四肢麻木被送往急诊室。她三周前接受了甲状旁腺切除术。在病史采集过程中，患者报告每天服用三次1克碳酸钙、每天两次0.5微克骨化三醇、每天一次10000单位胆钙化醇（维生素D3）、每天一次25毫克氯噻酮和每天一次300毫克厄贝沙坦。入院时，她的血钙水平为23毫克/分升，离子钙为12.03毫克/分升，pH值为7.59，碳酸氢根为33。她处于肾衰竭状态，肌酐为1.9毫克/分升（基线为0.8毫克/分升）。她的甲状旁腺激素（PTH）水平为0。诊断为CATS。她接受了静脉输液和呋塞米治疗，在血钙和肌酐水平恢复正常后的第5天出院。血钙过高、急性肾损伤和代谢性碱中毒三联征构成MAS。传统的MAS是由用于治疗消化性溃疡疾病的“西皮饮食”（含牛奶和碱）引起的。几十年来，使用过量钙和维生素D的患者也出现了相同的三联征症状，因此将其名称改为CAS。有CAS风险的一部分患者也因高血压使用噻嗪类利尿剂，这使他们更容易发生血钙过高和急性肾损伤。在这类患者中，使用CATS这个术语比MAS或CAS更合适。
