Medical Associates Clinic

 Quality Care Close To Home

Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 31 May 2006

HOW MEDICAL PROBLEMS ARE SOLVED

            The gentleman was 59 years old and considered himself a healthy individual.  He worked as an engineer designing roads and bridges.  He had been health conscious and participated in the routine screening procedures offered by the state government.

            He came to the clinic because of non-specific ill feelings.  He described occasional nausea and vomiting which was worse in the past three weeks.  He had always been slightly heavier than he wanted to be and thus was not alarmed by a 10-pound weight loss as it occurred over the last three months.  But this weight loss occurred without any effort or intent on his part.  He acknowledged that food just didn’t taste good.  He recalled that he never used to have to get up at night to pass urine but now he had to get up two or three times at night to pass urine.  He came to the clinic because he thought he had diabetes based upon the extra urine that he was passing.

            A physical examination was done and was unremarkable.  He appeared to be a relatively robust individual, although there was gauntness to his face suggesting recent weight loss.  A chest film was done showing no abnormality.  His electrocardiogram was normal.  The blood count was normal.  He was not anemic.  His urine was normal.  There was no evidence of sugar in the urine to suggest that he might be diabetic, as he had suspected.

            But then, his comprehensive blood panel returned and showed a serum calcium of 13 mg%.  Calcium is a critical component of the blood.  The normal values are around 8.5 mg% to 10.5 mg%.  The symptoms of having a high blood calcium are relatively well known and they include all of the ones mentioned above.  Specifically, weight loss, loss of appetite, nausea, vomiting, constipation and increased urine output are variable but predictable symptoms of high blood calcium and he fit the mold.

            But then the question arises regarding what is causing a high blood calcium.  The problem-solving process begins with recognition that when there is too much of something in the blood, it either represents too much of that component getting into the blood or not enough getting out.  In the case of calcium, the causes of not enough calcium getting out the blood are very rare. The solution to this man’s problem really represents recognizing the causes of too much calcium getting into the blood.

            The cycle of how calcium gets in to the blood begins with how much calcium comes in through the gastrointestinal tract.  Normally, a person takes in about a 1,000 mg of calcium per day.  About 100 mg of that is absorbed into the blood and the other 900 mg are excreted in the stool.  This seems a very wasteful system but it provides a huge reservoir for taking up more calcium as the body needs.  Thus, the first thing to think about when there is too much calcium in the blood could be that the person is eating Tums by the roll and simply overwhelming the bowels ability to barricade calcium out of the blood stream when needed.  There is a condition called the milk-alkali syndrome in which the person drinks large amounts of milk and takes a large number of Tums because of abdominal discomfort.  This can result in way too much calcium being presented to the gut and it simply can’t regulate the blood calcium which then gets too high.  In this particular gentleman, we worked out that that was not the case.

            A second possible cause of too much calcium in the blood, would be too much Vitamin D.  Vitamin D facilitates calcium absorption from the bowel into the blood stream. Too much Vitamin D can lead to overstimulation of the uptake of a normal amount of calcium in the bowel resulting in high blood calcium.   Talking with this gentleman, it was apparent that he was not taking excessive amounts of Vitamin D.

            When the possibility of too much calcium being absorbed from the bowel, either from calcium overload or Vitamin D intoxication is ruled out, the more ominous causes of high blood calcium has to be considered.  Specifically, human bones are in constant equilibrium with the blood.  If the blood calcium drops a slight amount, the body will dissolve a small amount of bone to replace calcium in the blood and keep it in the normal range.  But there are disease conditions in which too much bone is dissolved and the blood calcium gets too high, as it was with this gentleman.  So the next test that was done is called a bone scan.  By this test a radioactive material is injected in small amounts into the person’s blood stream and will localize in bone areas where calcium is being taken up too quickly.  The scan was normal.  This was an unexpected result but it basically ruled out that the person had a cancer with metastasis to the person’s bone.

            Now the healthcare professional is faced with further a dilemma on how to localize and find the cause of the high blood calcium.  There are four glands in the neck called the parathyroid glands.  They secrete a hormone called parathyroid hormone.  This hormone goes to the bone and causes it to dissolve calcium into the blood when it is needed.  This is a very sensitive regulatory system; but if one or more of these glands become unregulated dissolution of  too much bone can occur as seen in this gentleman.  There is a test that can measure how much parathyroid hormone is in the blood and when this test was done on this gentleman it was normal, even very low.  This proved that the parathyroid hormone and parathyroid glands were not the issue here.

            Finally, the person’s possibilities were narrowed down.  On re-examining his chemistry panel that was done earlier, it was seen that the amount of protein in his blood was also somewhat high. This was a flag suggesting that he might have a disease called multiple myeloma.  Multiple myeloma is a malignant condition in which the antibody-producing cells in the bone marrow make too much antibody.  They erode the bone causing the calcium to go high, but for some reason, do not create an abnormal bone scan as a cancer will.  Further tests were done and then a bone marrow biopsy was done.  These proved that the gentleman had multiple myeloma as the basic cause for his high blood calcium.

            Now that we had the cause for his high blood calcium, the next question was how to treat this gentleman.  We know that if we can get the malignancy under control, the high blood calcium will go down by itself. However in the interval, he was treated with large doses of cortisone. It is known that this will make the calcium go down, stop the nausea, vomiting, stimulate his appetite and again regain well-being.

            The last step in his care is how to deal with the malignancy.  Fortunately, in the last many years, there have been a number of chemotherapies to treat the condition called multiple myeloma.  This particular gentleman was treated with two medications called prednisone and Alkeran on a monthly basis.  For four days a month, he took a large dose of cortisone and an anti-cancer drug called Alkeran.  This reduced the amount of abnormal protein in his blood by more than 60%.  It also stopped the high blood calcium problem and his well-being was re-established.

            Multiple myeloma is like any other malignancy.  It is not possible to really cure it but it can be effectively treated and controlled.  In the case of this particular gentleman whom I first encountered six years ago, the result has been very gratifying. Specifically once a month, he takes the two medications, mentioned above, and his abnormal protein in his blood is controlled at a slightly high level but enough not to cause him symptoms.  Whether the tumor will ever break through the chemotherapy offered and get out of control is not clear.  But, fortunately, on this particular type of cancer, there are other chemotherapies available if that ever happens.

            Medical problems are solved by sifting through all of the different information available, trying to put something together that fits and makes sense and then getting a treatment program that will deal with the problem.  Most of the time, these problems can be solved in your local clinics with very satisfactory results.  About 10% of the time, the problem is more complex and specialty care is recommended.  It is at that time, that the healthcare providers at your local clinics refer the person on to a specialist who then prescribes a treatment program that can be administered through your local clinics.  The colds, flu, and earaches that we deal with 4-6 times a day are interspersed with problems that are much more complex such as this.