Milk-Alkali Syndrome Clinical Presentation

  • Author: R Hal Scofield, MD; Chief Editor: George T Griffing, MD   more...
 
Updated: Jan 6, 2012
 

History

Milk-alkali syndrome is a diagnosis of history and of exclusion; other potential causes of hypercalcemia must be eliminated. A careful history of all medicines, including OTC medications, should be obtained. This includes actual inspection of bottles to determine ingredients, when needed.

In the author's experience, failure to diagnose milk-alkali syndrome is usually related to a failure to obtain a full history of OTC medications. Moreover, in a series of 11 patients with milk-alkali syndrome, only 5 had the diagnosis made while hospitalized. The remaining 6 were diagnosed only with chart review in retrospect.[7] Patients discharged without a specific diagnosis are likely to continue excess intake of calcium carbonate and develop hypercalcemia again.

No specific or characteristic physical findings are described for milk-alkali syndrome; the signs and symptoms are those of hypercalcemia from any cause. Central nervous system symptoms may include the following:

  • Fatigue
  • Depression
  • Malaise
  • Confusion/mental status changes

GI symptoms may include the following:

  • Nausea
  • Vomiting
  • Constipation

Genitourinary symptoms may include the following:

  • Urinary frequency
  • Renal tubular defects
  • Renal failure

Cardiac symptoms may include the following:

  • Electrocardiographic changes (short QT interval)[32]
  • Arrhythmias
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

R Hal Scofield, MD  Professor, Department of Medicine, Section of Endocrinology, Associate Dean for Clinical and Translational Research, University of Oklahoma College of Medicine; Associate Member, Arthritis and Immunology Program, Oklahoma Medical Research Foundation

R Hal Scofield, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, American Diabetes Association, American Federation for Medical Research, Endocrine Society, and Oklahoma State Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Thuy-Trang Nguyen  University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Romesh Khardori, MD, PhD, FACP Former Professor, Department of Medicine, Former Chief, Division of Endocrinology, Metabolism, and Molecular Medicine, Southern Illinois University School of Medicine

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

  1. Medarov BI. Milk-alkali syndrome. Mayo Clin Proc. Mar 2009;84(3):261-7. [Medline]. [Full Text].

  2. Kleinig TJ, Torpy DJ. Milk-Alkali syndrome: broadening the spectrum of causes to allow early recognition. Intern Med J. Jun 2004;34(6):366-7. [Medline].

  3. Irtiza-Ali A, Waldek S, Lamerton E, Pennell A, Kalra PA. Milk alkali syndrome associated with excessive ingestion of Rennie: case reports. J Ren Care. Jun 2008;34(2):64-7. [Medline].

  4. Jousten E, Guffens P. Milk-alkali syndrome caused by ingestion of antacid tablets. Acta Clin Belg. Mar-Apr 2008;63(2):103-6. [Medline].

  5. Addington S, Larson N, Scofield RH. Milk-alkali syndrome in pre-eclamptic pregnancy: report of a patient and evaluation of albumin-corrected calcium in pre-eclamptic pregnancies. J Okla State Med Assoc. Sep 2006;99(9):480-4. [Medline].

  6. Beall DP, Scofield RH. Milk-alkali syndrome associated with calcium carbonate consumption. Report of 7 patients with parathyroid hormone levels and an estimate of prevalence among patients hospitalized with hypercalcemia. Medicine (Baltimore). 1995;74(2):89-96. [Medline].

  7. Picolos MK, Lavis VR, Orlander PR. Milk-alkali syndrome is a major cause of hypercalcaemia among non-end-stage renal disease (non-ESRD) inpatients. Clin Endocrinol (Oxf). Nov 2005;63(5):566-76. [Medline].

  8. Wu KD, Chuang RB, Wu FL, Hsu WA, Jan IS, Tsai KS. The milk-alkali syndrome caused by betelnuts in oyster shell paste. J Toxicol Clin Toxicol. 1996;34(6):741-5. [Medline].

  9. Gibbs CJ, Lee HA. Milk-alkali syndrome due to Caved-S. J R Soc Med. Aug 1992;85(8):498-9. [Medline]. [Full Text].

  10. Nakanishi T, Uyama O, Yamada T, Sugita M. Sustained metabolic alkalosis associated with development of the milk-alkali syndrome. Nephron. 1992;60(2):251. [Medline].

  11. Brandwein SL, Sigman KM. Case report: milk-alkali syndrome and pancreatitis. Am J Med Sci. Sep 1994;308(3):173-6. [Medline].

  12. Campbell SB, Macfarlane DJ, Fleming SJ, Khafagi FA. Increased skeletal uptake of Tc-99m methylene diphosphonate in milk-alkali syndrome. Clin Nucl Med. Mar 1994;19(3):207-11. [Medline].

  13. Duthie JS, Solanki HP, Krishnamurthy M, Chertow BS. Milk-alkali syndrome with metastatic calcification. Am J Med. Jul 1995;99(1):102-3. [Medline].

  14. Spital A, Freedman Z. Severe hypercalcemia in a woman with renal failure. Am J Kidney Dis. Oct 1995;26(4):674-7. [Medline].

  15. Fiorino AS. Hypercalcemia and alkalosis due to the milk-alkali syndrome: a case report and review. Yale J Biol Med. Nov-Dec 1996;69(6):517-23. [Medline]. [Full Text].

  16. Lin SH, Lin YF, Shieh SD. Milk-alkali syndrome in an aged patient with osteoporosis and fractures. Nephron. 1996;73(3):496-7. [Medline].

  17. Muldowney WP, Mazbar SA. Rolaids-yogurt syndrome: a 1990s version of milk-alkali syndrome. Am J Kidney Dis. Feb 1996;27(2):270-2. [Medline].

  18. Sulkin T, Krentz AJ. Iatrogenic recurrent severe hypercalcaemia and renal impairment. Postgrad Med J. Dec 2000;76(902):800, 807. [Medline]. [Full Text].

  19. Camidge R, Peaston R. Recommended dose antacids and severe hypercalcaemia. Br J Clin Pharmacol. Sep 2001;52(3):341-2. [Medline]. [Full Text].

  20. George S, Clark JD. Milk alkali syndrome-an unusual syndrome causing an unusual complication. Postgrad Med J. Jul 2000;76(897):422-3. [Medline]. [Full Text].

  21. Vanpee D, Delgrange E, Gillet JB, Donckier J. Ingestion of antacid tablets (Rennie) and acute confusion. J Emerg Med. Aug 2000;19(2):169-71. [Medline].

  22. Liu SW, Kumar AM, Nadel ES, Brown DF. A young woman with altered mental status. J Emerg Med. May 2002;22(4):405-8. [Medline].

  23. Robertson WC Jr. Calcium carbonate consumption during pregnancy: an unusual cause of neonatal hypocalcemia. J Child Neurol. Nov 2002;17(11):853-5. [Medline].

  24. Morton A. Milk-alkali syndrome in pregnancy, associated with elevated levels of parathyroid hormone-related protein. Intern Med J. Sep-Oct 2002;32(9-10):492-3. [Medline].

  25. Gordon MV, McMahon LP, Hamblin PS. Life-threatening milk-alkali syndrome resulting from antacid ingestion during pregnancy. Med J Aust. Apr 4 2005;182(7):350-1. [Medline].

  26. Verburg FA, van Zanten RA, Brouwer RM, Woittiez AJ, Veneman TF. [A man with a classic serious milk-alkali syndrome and a carcinoma of the stomach]. Ned Tijdschr Geneeskd. Jul 22 2006;150(29):1624-7. [Medline].

  27. Ennen CS, Magann EF. Milk-alkali syndrome presenting as acute renal insufficiency during pregnancy. Obstet Gynecol. Sep 2006;108(3 Pt 2):785-6. [Medline].

  28. Caruso JB, Patel RM, Julka K, Parish DC. Health-behavior induced disease: return of the milk-alkali syndrome. J Gen Intern Med. Jul 2007;22(7):1053-5. [Medline]. [Full Text].

  29. Dinnerstein E, McDonald BC, Cleavinger HB, Thadani VM, Jobst BC. Mesial temporal sclerosis after status epilepticus due to milk alkali syndrome. Seizure. Apr 2008;17(3):292-5. [Medline].

  30. Kaklamanos M, Perros P. Milk alkali syndrome without the milk. BMJ. Aug 25 2007;335(7616):397-8. [Medline]. [Full Text].

  31. Shah BK, Gowda S, Prabhu H, Vieira J, Mahaseth HC. Modern milk alkali syndrome--a preventable serious condition. N Z Med J. Sep 21 2007;120(1262):U2734. [Medline].

  32. Miller PD. Vitamin D, calcium, and cardiovascular mortality: a perspective from a plenary lecture given at the annual meeting of the American Association of Clinical Endocrinologists. Endocr Pract. Sep 1 2011;17(5):798-806. [Medline].

  33. Papworth K, Grankvist K, Ljungberg B, Rasmuson T. Parathyroid hormone-related protein and serum calcium in patients with renal cell carcinoma. Tumour Biol. Jul-Aug 2005;26(4):201-6. [Medline].

  34. LeGrand SB, Leskuski D, Zama I. Narrative review: furosemide for hypercalcemia: an unproven yet common practice. Ann Intern Med. Aug 19 2008;149(4):259-63. [Medline].

 
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The hospital course of a patient with milk-alkali syndrome who, during treatment, developed symptomatic hypocalcemia with a markedly elevated serum parathyroid hormone level (PTH). Thirty days after discharge, the calcium and PTH levels were normal.
Table. Summary of 65 Consecutively Reported Adult Patients With Milk-Alkali Syndrome*
Mean Age51 Years (Range, 24-95 y)
Sex35 men and 43 women
Calcium sourceCalcium carbonate in all but 1
Ingestion of bicarbonateIn 7 patients
Ingestion of milkIn 20 patients (plus one who ate yogurt)
Mean serum calcium15.1mg/dL (3.75mmol/L) (range, 11.1-27.5mg/dL)
High serum phosphorusIn 12 patients
Permanent renal insufficiencyIn 20 of 57 patients eligible for evaluation
Parathyroid explorationIn 3 patients
Hypocalcemia with treatmentIn 16 patients
*These data are derived from the 7 patients reported, plus the 28 reviewed in Beall and Scofield, 1995,[6] as well as additional patients reported by Gibbs and Lee, 1992;[9] Nakanishi et al, 1992[10] ; Brandwein and Sigman, 1994[11] ; Campbell et al, 1994[12] ; Duthie et al, 1995[13] ; Spital and Freedman, 1995[14] ; Fiorino, 1996[15] ; Lin et al, 1996[16] ; Muldowney and Mazbar, 1996[17] ; Sulkin and Krentz, 1999[18] ;



Camidge and Peaston, 2000[19] ; George and Clark, 2000[20] ; Vanpee et al, 2000[21] ; Liu et al, 2002[22] ; Robertson, 2002[23] ; Morton, 2002[24] ; Kleinig and Torpy, 2004[2] ; Picolos et al, 2005[7] ; Gordon et al, 2005[25] ; Addington et al, 2006[5] ; Verburg et al, 2006[26] ; Ennen and Magann, 2006[27] ; Caruso et al, 2007[28] ; Dinnerstein et al, 2007[29] ; Javid et al, 2007; Kaklamanos and Perros, 2007[30] ; Shah et al, 2007[31] ; Irtiza-Ali et al, 2008[3] ; and Jousten and Guffens, 2008.[4]



Two of the patients were pregnant.



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