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Hypercalcemia Clinical Presentation

  • Author: Mahendra Agraharkar, MD, MBBS, FACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
Updated: Aug 02, 2016


The mnemonic "stones, bones, abdominal moans, and psychic groans" describes the constellation of symptoms and signs of hypercalcemia. These may be due directly to the hypercalcemia, to increased calcium and phosphate excretion, or to skeletal changes.

The presentation in a patient with hypercalcemia varies with how fast and how far the calcium level rises, as well as the sensitivity of the individual to elevated calcium levels. Mild prolonged hypercalcemia may produce mild or no symptoms, or recurring problems such as kidney stones. Sudden-onset and severe hypercalcemia may cause dramatic symptoms, usually including confusion and lethargy, possibly leading quickly to death.

Central nervous system effects include the following:

  • Lethargy
  • Weakness
  • Confusion
  • Coma

Renal effects include the following:

  • Polyuria
  • Nocturia
  • Dehydration
  • Renal stones
  • Renal failure

Gastrointestinal effects include the following:

  • Constipation
  • Nausea
  • Anorexia
  • Pancreatitis
  • Gastric ulcer

Cardiac effects include syncope from arrhythmias.


Physical Examination

Most patients with hypercalcemia do not have any specific findings on physical examination. Those with higher calcium levels may have findings that are more striking. Evidence of the underlying cause may be found, such as a suggestive breast mass in someone with hypercalcemia secondary to malignancy.

Nervous system findings include the following:

  • Confusion
  • Hypotonia
  • Hyporeflexia
  • Paresis
  • Coma

Renal findings include the following:

  • Volume depletion
  • Signs of renal failure

Gastrointestinal findings include the following:

  • Fecal impaction (from constipation)
  • Signs of pancreatitis
  • Signs of malignancy (eg, enlarged liver or masses)

Cardiac findings include the following:

  • Arrhythmias
  • Hypotension
  • Shortened QT interval

Ophthalmic findings may include band keratopathy, which is calcium precipitation in a horizontal band across the cornea in the palpebral aperture.

Contributor Information and Disclosures

Mahendra Agraharkar, MD, MBBS, FACP FASN, Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP is a member of the following medical societies: American College of Physicians, American Society of Nephrology, National Kidney Foundation

Disclosure: Received ownership interest/medical directorship from South Shore DaVita Dialysis Center for other; Received ownership/medical directorship from Space City Dialysis /American Renal Associates for same; Received ownership interest from US Renal Care for other.


O David Dellinger, III, MD Assistant Professor, Departments of Family Medicine and Internal Medicine, University of Alabama School of Medicine at Birmingham

O David Dellinger, III, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Physicians-American Society of Internal Medicine, American Geriatrics Society, AMDA - The Society for Post-Acute and Long-Term Care Medicine, American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Arun Kumar Gangakhedkar, MD, FRACP Consultant in General Pediatrics, Starship Children's Hospital/Waitakere Hospital, New Zealand

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christie P Thomas, MBBS, FRCP, FASN, FAHA Professor, Department of Internal Medicine, Division of Nephrology, Departments of Pediatrics and Obstetrics and Gynecology, Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics

Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, Royal College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.

  1. McKay CP, Portale A. Emerging topics in pediatric bone and mineral disorders 2008. Semin Nephrol. 2009 Jul. 29(4):370-8. [Medline].

  2. Guarnieri V, Canaff L, Yun FH, et al. Calcium-Sensing Receptor (CASR) Mutations in Hypercalcemic States: Studies from a Single Endocrine Clinic Over Three Years. J Clin Endocrinol Metab. 2010 Feb 17. [Medline].

  3. Nissen PH, Christensen SE, Wallace A, et al. Multiplex ligation-dependent probe amplification (MLPA) screening for exon copy number variation in the calcium sensing receptor gene: no large rearrangements identified in patients with calcium metabolic disorders. Clin Endocrinol (Oxf). 2009 Nov 11. [Medline].

  4. Luna-Cabrera F, Justicia-Rull EA, Caricol-Pérez MP, et al. Incidence of hypercalcemia, hypercalciuria and related factors in patients treated with recombinant human parathyroid hormone (1-84). Minerva Med. 2012 Apr. 103(2):103-10. [Medline].

  5. Vanstone MB, Oberfield SE, Shader L, Ardeshirpour L, Carpenter TO. Hypercalcemia in Children Receiving Pharmacologic Doses of Vitamin D. Pediatrics. 2012 Mar 12. [Medline].

  6. Sharma OP. Vitamin D, calcium, and sarcoidosis. Chest. 1996. 109(2):535-539. [Medline].

  7. Griebeler ML, Kearns AE, Ryu E, Thapa P, Hathcock MA, Melton LJ 3rd, et al. Thiazide-Associated Hypercalcemia: Incidence and Association With Primary Hyperparathyroidism Over Two Decades. J Clin Endocrinol Metab. 2016 Mar. 101 (3):1166-73. [Medline].

  8. Vargas-Poussou R, Mansour-Hendili L, Baron S, et al. Familial Hypocalciuric Hypercalcemia Types 1 and 3 and Primary Hyperparathyroidism: Similarities and Differences. J Clin Endocrinol Metab. 2016 May. 101 (5):2185-95. [Medline].

  9. Gastanaga VM, Schwartzberg LS, Jain RK, Pirolli M, Quach D, Quigley JM, et al. Prevalence of hypercalcemia among cancer patients in the United States. Cancer Med. 2016 Jun 5. [Medline].

  10. Royer AM, Maclellan RA, Daniel Stanley J, Willingham TB, Heath Giles W. Hypercalcemia in the emergency department: a missed opportunity. Am Surg. 2014 Aug. 80(8):732-5. [Medline].

  11. Cafforio P, Savonarola A, Stucci S, De Matteo M, Tucci M, Brunetti AE, et al. PTHrP produced by myeloma plasma cells regulates their survival and pro-osteoclast activity for bone disease progression. J Bone Miner Res. 2014 Jan. 29(1):55-66. [Medline].

  12. Goldner W. Cancer-Related Hypercalcemia. J Oncol Pract. 2016 May. 12 (5):426-32. [Medline].

  13. Alsirafy SA, Sroor MY, Al-Shahri MZ. Hypercalcemia in advanced head and neck squamous cell carcinoma: prevalence and potential impact on palliative care. J Support Oncol. 2009 Sep-Oct. 7(5):154-7. [Medline].

  14. Makras P, Papapoulos SE. Medical treatment of hypercalcaemia. Hormones (Athens). 2009 Apr-Jun. 8(2):83-95. [Medline]. [Full Text].

  15. Brooks M. FDA Approves New Indication for Denosumab (Xgeva). Medscape Medical News. Available at Accessed: December 13, 2014.

  16. Hu MI, Glezerman IG, Leboulleux S, Insogna K, Gucalp R, Misiorowski W, et al. Denosumab for treatment of hypercalcemia of malignancy. J Clin Endocrinol Metab. 2014 Sep. 99(9):3144-52. [Medline]. [Full Text].

  17. Bergenfelz AO, Jansson SK, Wallin GK, et al. Impact of modern techniques on short-term outcome after surgery for primary hyperparathyroidism: a multicenter study comprising 2,708 patients. Langenbecks Arch Surg. 2009 Jul 18. [Medline].

  18. Low TH, Clark J, Gao K, et al. Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism. ANZ J Surg. 2009 May. 79(5):378-82. [Medline].

  19. Padhi D, Harris R. Clinical pharmacokinetic and pharmacodynamic profile of cinacalcet hydrochloride. Clin Pharmacokinet. 2009. 48(5):303-11. [Medline].

  20. Marcocci C, Chanson P, Shoback D, et al. Cinacalcet reduces serum calcium concentrations in patients with intractable primary hyperparathyroidism. J Clin Endocrinol Metab. 2009 Jun 2. [Medline].

  21. al Zahrani A, Levine MA. Primary hyperparathyroidism. Lancet. 1997 Apr 26. 349(9060):1233-8. [Medline].

  22. Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003 May 1. 67(9):1959-66. [Medline].

  23. Ganong CA, Kappy MS. Hypercalcemia. In: Berman S, ed. Pediatric Decision Making. 3rd ed. St. Louis, Mo: Mosby-Year Book; 1996:. 128-31.

  24. Hoenderop JG, Nilius B, Bindels RJ. Molecular mechanism of active Ca2+ reabsorption in the distal nephron. Annu Rev Physiol. 2002. 64:529-49. [Medline].

  25. Inzucchi SE. Management of hypercalcemia. Diagnostic workup, therapeutic options for hyperparathyroidism and other common causes. Postgrad Med. 2004 May. 115(5):27-36. [Medline].

  26. Pearce SH. Calcium homeostasis and disorders of the calcium-sensing receptor. J R Coll Physicians Lond. 1998 Jan-Feb. 32(1):10-4. [Medline].

  27. Strewler GJ. The physiology of parathyroid hormone-related protein. N Engl J Med. 2000 Jan 20. 342(3):177-85. [Medline].

Investigations flowchart.
Vitamin D metabolism.
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