Malignant and non-malignant causes of hypercalcemia: A retrospective study at a tertiary care hospital in Pakistan

Background: Hypercalcemia is a common electrolyte abnormality presenting with a variety of symptoms. The common causes are primary hyperparathyroidism and malignancy associated with hypercalcemia. However, iatrogenic hypercalcemia with the overzealous use of vitamin D has now emerged as another important cause of hypercalcemia over the past decade.Objective: This study aims to evaluate the causes of hypercalcemia, management strategies, and outcomes in patients admitted with hypercalcemia in a tertiary care hospital. Method: It is a retrospective study done at Aga Khan University Hospital (AKUH), Karachi after taking approval from the ethical review committee (ERC). Data were gathered about all patients admitted from 1st January 2008 to 31st December 2018. A total of 1142 patients were included in the study and their calcium levels were noted. Along with demographic details, data pertaining to their diagnosis and all investigations done to evaluate the causes of hypercalcemia were noted in a pre-defined questionnaire.Results: A total of 814 patients having hypercalcemia were included in the final analysis and their mean age was 60.8 ± 14.1 years. Male and female patients were 45.4% and 54.6%, respectively, and their mean hospital stay was 6.2 ± 5.8 days. The most common cause of hypercalcemia was malignant solid tumors (49.1%), followed by hematological malignancy (16.5%), hyperparathyroidism (10.9%), definite vitamin D toxicity (8%), chronic kidney disease (4.9%), chronic granulomatous diseases (4.7%), and probable vitamin D toxicity (3.5%). The oral cavity carcinoma (17.7%) was the most common solid tumor associated with hypercalcemia. Amongst hematological malignancy, multiple myeloma (14.4%) was the most common one. Out of 814 patients admitted with hypercalcemia, 601 (74%) patients recovered from hypercalcemia, while mortality was observed in 129 (16%) patients. Of those who expired, 110 (85.3%) had malignancy either solid tumor or hematological.Conclusion: Malignancy is the most common cause of hypercalcemia in admitted patients. The knowledge of hypercalcemia\u27s causes is of great importance so that targeted investigations can be done. Not only will it minimize the cost burden and shorten the hospitalization of patients; it will also help the physicians to decide the appropriate management accordingly. Moreover, vitamin D toxicity was also observed in a significant number of patients which highlights the common practice of using higher doses of vitamin D by physicians

Unusual presentation of a young man with disseminated tuberculosis and right ventricular mass

We report a 22-year-old man who presented to the emergency department with worsening shortness of breath and chronic fever for 2 months. Physical examination was unremarkable except for raised jugular venous pressure and palpable liver. Echocardiogram showed a large right ventricular mass causing obstruction at tricuspid valve. A subsequent chest CT scan confirmed the presence of a large mass in the right ventricle. There were multiple enlarged lymph nodes and consolidation in the right upper lobe. Diagnosis of disseminated tuberculosis(TB) was made and later confirmed by histopathology of lymph node biopsy along with positive sputum culture for acid-fast bacilli. Remarkable recovery was observed on antituberculous therapy, with complete disappearance of the cardiac mass on echocardiogram, at 1-year follow-up. Although unusual and rare, myocardial involvement as a large mass should be kept in mind while treating patients with disseminated TB

Isolated ligamentum flavum ossification in primary hypoparathyroidism

Basckground: The ligamenta flava can undergo ossification and calcification resulting in myelopathy. Only seven cases of ligamentumflavum ossification in association with hypoparathyroidism have been reported, most of which had concurrent osseous changes in other spinal ligaments. Here, we report a patient with hypoparathyroidism who presented ith ligamentum flavum ossification causing both cervical and thoracic myelopathy. Case description: A 43-year-old male presented with backache, urinary retention, and lower limb weakness for the last few days. Magnetic resonance imaging scan showed ossification of the ligamentum flavum in the cervical and thoracic regions, with severe spinal stenosis. Following spinal decompressive surgery, the patient made a complete recovery. Primary hypoparathyroidism was found to be the underlying cause for ligamentum flavum ossification. Conclusion: Ossification of ligamentum flavum secondary to hypoparathyroidism should be considered as a possible cause of myelopathy in all patients presenting with symptoms of spinal cord compression

Biology of Spodoptera litura on natural and artificial diet under laboratory conditions

Armyworm, Spodoptera litura (Lepidoptera; Noctuidae) is one of the most economically significant insect pests in global agriculture. The current study was performed to study the biology of S. litura under laboratory conditions. In the current study, the biological parameters of pests i.e., egg, larva, pupa and adult along with the duration were determined. The mean incubation period of pests on cabbage, maize and artificial diet was 2.86±0.33, 3.09 ± 0.12 and 3.97±0.77 days, respectively. S. litura had five instars. The mean developmental period of the first, second, third, fourth, fifth and sixth larval instar on cabbage was 3.44±0.11, 2.09±0.12, 4.11±0.12, 3.00±0.20, 6.68±0.23 and 5.94±0.18 days, respectively while 2.81±0.77, 3.55±0.33, 3.64±0.45, 4.43±0.71, 6.55±0.21 and 5.98±0.19 days on the maize, respectively. The mean developmental periods were 3.85±0.54, 3.45±0.63, 3.67±0.67, 4.37±0.82, 6.55±0.23 and 5.30±0.38 days of first, second, third, fourth, fifth and sixth larval instars on artificial diet, respectively. The mean total life period of S. litura was 33.43±5.86 days on cabbage and 34.79±6.95 days on maize while 35.98±7.86 days on an artificial diet. The longest developmental period of S. litura was recorded on the artificial diet while the minimum was on cabbage. The mean developmental period of pupa was 7.50±0.71 days on cabbage, 9.87±0.94 days on maize and 11.63±0.99 days on an artificial diet. Females were short-lived as compared to males. The pre-oviposition, oviposition and post-ovipositional period of S. litura on cabbage were recorded as a minimum while maximum on an artificial diet. The maximum number of eggs laid by females with the highest hatchability on cabbage followed by maize and artificial diet. An artificial diet was not good for pest development and growth as compared to a natural diet i.e., cabbage and maize. The findings will provide basic information about food pests which help in pest management

Foreign Direct Investment and Economic Growth: Evidence from Pakistan

This study finds the relationship between FDI and other indicators of economic growth i.e. employment rate, exports and foreign reserves with GDP through Johansen cointegrration and VECM over the period of 1963-2014. Unit root was checked through ADF test and all variables are integrated at 1st different. The results confirmed that an increase in FDI has positive impact on the economic growth of Pakistan both in the short and long run. Our results are likely to provide an opportunity to frame some policy implications. Hence the authorities should positively concentrate on maximum utilization of resources to increase FDI in order to increase GDP growth rate

Diabetic ketoacidosis associated with tacrolimus in solid organ transplant recipients

Diabetic ketoacidosis in patients receiving tacrolimus in the post-transplant setting is rare. We describe two such cases in solid-organ transplant recipients. The first patient, a 17-year-old male, presented with severe diabetic ketoacidosis and was managed with intravenous fluids and insulin infusion. He was a known case of Laurence-Moon-Bardet-Biedl syndrome and had received a renal transplant 2 years ago and was receiving tacrolimus since then. Although diabetic ketoacidosis resolved in 24 hours, large doses of subcutaneous insulin (upto 130 units per day) were needed to keep serum glucose within the normal range. Substitution of tacrolimus with cyclosporine obviated the need for insulin or oral hypoglycaemics. The second patient, a 55-year-old woman, presented with a history of polyuria for 3 days. She had received a hepatic transplant 2 years ago and tacrolimus was being used since then. Mild diabetic ketoacidosis was managed with fluid resuscitation and subcutaneous insulin. Her insulin requirement after an uneventful recovery has been 54 - 70 units per day. Clinicians should be cognizant of the possibility of hyperglycaemic crisis presenting as sudden onset of diabetic ketocidosis in patients receiving tacrolimus. Use of an alternative calcineurin inhibitor may provide a safer solution to minimize future morbidity in such patients

Vitamin-D Toxicity And Other Non-Malignant Causes Of Hypercalcemia: A Retrospective Study At A Tertiary Care Hospital In Pakistan

Background: Hypercalcemia is a common clinical problem; primary hyperparathyroidism and malignancy is commonest causes of hypercalcemia. Aetiology of hypercalcemia are changing, causes that were diseases of the past like Vitamin-D toxicity and milk alkali syndrome are observed more often. Vitamin-D deficiency is an important problem and overzealous replacement of Vitamin-D has been observed, suspected to cause toxicity. Methods: This was a retrospective review of patients admitted at the Aga Khan University Hospital from January 2008 to December 2013 with hypercalcemia. We reviewed the electronic health records for laboratory and radiological studies, and discharge summaries to establish the cause of hypercalcemia. Patients with solid tumour malignancy were excluded from the analysis. The treatment records and hospital course of patients diagnosed with Vitamin-D toxicity were also reviewed. Results: Primary hyperparathyroidism was the most common cause of hypercalcemia comprising 41 (28.2 %) patients. Vitamin-D toxicity was present in 25 (17.3%) and probable Vitamin-D toxicity 11 (7.6 %) inpatients. Vitamin-D toxicity and probable Vitamin-D toxicity together comprised 36 (24.8%) cases. Other causes of hypercalcemia included multiple myeloma 18 (12.4%) patients, tuberculosis 6 (4.1%) patients, chronic kidney disease6 (4.1%) cases, sarcoidosis 4 (2.7%) and lymphoma 3 (2.0%) patients. In 29(20%) patients a cause of hypercalcemia could not be determined and were labelled as undiagnosed cases. Conclusion: Vitamin-D toxicity was the second commonest cause of hypercalcemia after primary hyperparathyroidism. Knowledge of the prevalent and emerging causes of hypercalcemia is important for prompt diagnosis and treatment.

Raised levels of IFN-gamma and IL-13 are associated with pre-diabetes amongst newly diagnosed patients with tuberculosis

Objective: To investigate pre-diabetes and diabetes in newly-diagnosed tuberculosis patients and to assess the association of serum cytokine levels with diabetes status. Methods: The cross-sectional study was conducted at Indus Hospital and The Aga Khan University Hospital, Karachi from May to November 2015, and included patients of either gender aged 18 years or more with a confirmed diagnosis of tuberculosis who were either newly diagnosed or had received up to 1 month of anti-tuberculosis therapy were included. Patients were enrolled from among those presenting to the clinics at Indus Hospital, Karachi, and the Department of Medicine, Aga Khan University Hospital (AKUH), Karachi. The patients were tested for glycosylated haemoglobin and random blood glucose. Diabetes was defined as HbA1c \u3e6.5%; pre-diabetes as HbA1c=5.7-6.4%; and normoglycaemic as HbA1c \u3c5.7%. Serum cytokines were investigated using the Bio-plex 27, Bio-Rad assay. SPSS version 19.0 was used for data analysis. Results: Of the 211 subjects, 110(52%) were females and 101(48%) were males. The overall median age of the sample was 26 years, and 100(47.3%) subjects were underweight. Of the total, 24(11.4%) had diabetes and 45(21.3%) had pre-diabetes. Of the diabetics, only 7(29%) knew their status prior to screening. Interferon-gamma and interleukin-13 were significantly different among tuberculosis patients with diabetes, pre-diabetes and normoglycaemia (p\u3c0.05). Glycosylated haemoglobin levels showed a significant correlation with interferon-gamma levels. Conclusions: Raised interleukin-13 and interferon-gamma levels in newly-diagnosed tuberculosis patients with pre-diabetes