A Curious Case of Hypercalcemia
Introduction: Hypercalcemia is a clinical entity commonly seen on Internal Medicine inpatient units. Through standard diagnostic algorithms, the etiology of most cases can be elucidated. Brivaracetam is a novel anti-epileptic agent that binds synaptic vesicle protein 2A shown to significantly reduce seizure frequency. We describe the first case of hypercalcemia secondary to brivaracetam.
Case Description: A 53 year-old-male with medically refractory epilepsy, diabetes mellitus and pancytopenia secondary to anti-epileptic medications who presented to hospital with fatigue and constipation. Investigations revealed creatinine of 390umol/L (baseline 110umol/L) and uncorrected calcium of 3.6mmol/L. Serum parathyroid hormone level was 1.6, serum protein electrophoresis did not reveal a monoclonal band and urine calcium was elevated. Computed tomography of his chest abdomen and pelvis showed no malignancy or granulomatous lesions. Positron emission tomography was negative. A bone marrow biopsy showed trilineage hematopoiesis and no features of malignancy. Fourteen days after drug cessation, intravenous fluid resuscitation and treatment with pamidronate as well as calcitonin, his calcium normalized.
Discussion: Excluding all other potential aetiologies of hypercalcemia and clinical as well as biochemical improvement following withdrawal of the drug brivaracetam was felt to be the causative agent. This case demonstrates the ability of brivaracetam to cause symptomatic severe hypercalcemia and emphasizes the need for care providers to monitor calcium while on therapy.
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