Hypercalcemia Secondary To Undiagnosed Metastatic Breast Cancer

A 78-year-old female is brought to her family doctor with the complain of strange behavior. According to her family, she has been more sleepy and weak throughout the last week. She is acting more withdrawn and depressed and seems to respond to nonexistent external stimuli (similar to small children’s imaginary play friends). When asked about her depression, she reports she is sad because a man in a clown suit  keeps telling her she is going to die. She complains of abdominal cramps and blames it on “being plugged up,” and her family reports no bowel movement for 2 days. She also notes chronic bone pain in her hips and back.
A physical exam is notable only for a 3 cm irregular mass in her right breast . The family thinks it is new. Her neurological exam is normal, except for her apparent confusion.

An ECG was done and what finding should you expect?

A) Peaked T-waves.
B) Diffuse ST-segment elevations.
C) Long QT interval.
D) Short QT interval.
E) B and D.

Answer And Discussion:


The correct answer is “E.”  Diffuse ST-segment elevations and Short QT interval.

This patient is likely to have hypercalcemia, probably from an undiagnosed metastatic breast cancer. The ECG in a patient with significant hypercalcemia will show a short QT interval; rarely there is diffuse ST elevation.
Hypocalcemia is associated with a long QT interval, which can occasionally lead to arrhythmias due to an R on T phenomenon (an R-wave of a PVC fuses with the previous T-wave predisposing to torsades de pointes).
Hypercalcemia produces symptoms in the:

• CNS (confusion, psychosis, depression), 
• GI system (abdominal pain, cramps, constipation), 
• kidneys (nephrolithiasis, polyuria, renal insufficiency),and 
• musculoskeletal system (weakness, myopathy, osteoporosis).

To help you remember the symptoms of hypercalcemia, use the phrase “stones, bones, moans, groans, and psychiatric overtones.”

Peaked T-waves are associated with hyperkalemia, and diffuse ST segment
elevations is a finding in pericarditis (and rarely hypercalcemia).