What are the symptoms and management of hypercalcemia in patients of various age groups and demographics?

Symptoms of Hypercalcemia

Hypercalcemia presents with a spectrum of symptoms ranging from none in mild cases to life-threatening manifestations in severe cases, affecting multiple organ systems including renal, gastrointestinal, neurologic, and cardiovascular systems.

Symptom Severity Based on Calcium Levels

Mild Hypercalcemia (Total Calcium <12 mg/dL or Ionized Calcium 5.6-8.0 mg/dL)

• Most patients are asymptomatic, though approximately 20% experience constitutional symptoms 1
• Fatigue is a common complaint in symptomatic mild hypercalcemia 1
• Constipation may occur even with mild elevations 1
• Symptoms are typically subtle and fewer compared to severe hypercalcemia 2

Moderate Hypercalcemia (Total Calcium 11-12 mg/dL)

• Polyuria (excessive urination) and polydipsia (excessive thirst) are hallmark renal manifestations 3, 4
• Nausea and vomiting are common gastrointestinal symptoms 3, 4
• Abdominal pain frequently occurs 3, 4
• Myalgia (muscle pain) may be present 3

Severe Hypercalcemia (Total Calcium ≥14 mg/dL or Ionized Calcium ≥10 mg/dL)

• Mental status changes including confusion, somnolence, and altered consciousness are prominent neurologic features 3, 4, 1
• Coma can develop in untreated severe cases 1
• Dehydration results from polyuria and reduced oral intake 3, 1
• Acute renal failure may complicate severe hypercalcemia 3
• Bradycardia (slow heart rate) is a cardiovascular manifestation 3, 4
• Hypotension can occur 3, 4

System-Specific Manifestations

Renal System

• Decreased glomerular filtration rate, particularly with underlying renal impairment 4
• Kidney stones (nephrolithiasis) are characteristic of chronic hyperparathyroidism-related hypercalcemia 2
• Nephrocalcinosis contributes to worsening hypercalcemia through impaired calcium excretion 5

Gastrointestinal System

• Nausea and vomiting are particularly common with calcium levels between 11-12 mg/dL 4
• Abdominal pain is a frequent complaint 4

Neurologic System

• Confusion and altered mental status occur especially when calcium exceeds 14 mg/dL 4
• Somnolence progressing to coma in untreated cases 1

Cardiovascular System

• Bradycardia in severe cases 4
• Hypotension 4
• QT interval prolongation on ECG 6

Musculoskeletal System

• Bone pain in chronic hypercalcemia 4
• Pathologic fractures with underlying metabolic bone disease 4
• Osteitis fibrosa cystica is characteristic of hyperparathyroidism 2

Special Population Considerations

Infants with Williams Syndrome

• Extreme irritability is a prominent feature 3
• Vomiting and constipation 3
• Muscle cramps 3

Malignancy-Associated Hypercalcemia

• Rapid onset with higher calcium levels and more severe symptoms compared to hyperparathyroidism 2
• Marked anemia is present 2
• Kidney stones and metabolic acidosis are notably absent (unlike hyperparathyroidism) 2

Primary Hyperparathyroidism

• Tends to be associated with lower calcium levels (<12 mg/dL) and longer duration (>6 months) 2
• Symptoms are usually fewer and more subtle 2
• Hyperchloremic metabolic acidosis may occur 2
• Kidney calculi are characteristic 2

Critical Clinical Pearls

The classic mnemonic "stones, bones, groans, and psychiatric overtones" captures the major symptom categories: kidney stones (renal), bone pain (skeletal), abdominal groans (GI symptoms), and confusion/altered mental status (neurologic) 7.

Rapid onset hypercalcemia developing over days to weeks causes more severe symptoms than chronic, slowly developing hypercalcemia, even at similar calcium levels 1.

Asymptomatic hypercalcemia is common with mild elevations, and many patients with primary hyperparathyroidism have a benign course 1, 7.