(Kiosk 6) Focal Musculoskeletal Pain in a Child with Hypercalcemia: A Case Report

Case Diagnosis: 16 year-old girl with complex congenital heart disease status post orthotopic heart transplant (OHT) who developed focal musculoskeletal pain in the setting of hypercalcemia.

Case Description or Program Description: The patient was admitted with worsening dyspnea in the setting of protein-losing enteropathy associated with congenital heart disease that ultimately required OHT due to circulatory collapse. Her post-operative course was complicated by refractory hypotension that required extracorporeal membrane oxygenation support. Her prolonged hospitalization and immobility was complicated by left-sided weakness and lower extremity (LE) neuropathic pain. Electromyographic findings were consistent with severe diffuse critical illness polyneuropathy. She was started on gabapentin with some improvement in neuropathic pain. Her serum calcium level began up-trending over the course of 3 weeks until they reached severe (>14mg/dL) levels. An extensive workup revealed the most likely etiology to be immobility. She developed worsening LE pain and left shoulder pain one week after onset of severe hypercalcemia. Her physical exam was most consistent with rotator cuff pathology, however musculoskeletal ultrasound of her left shoulder was unremarkable.

Setting: Tertiary care pediatric hospital

Assessment/Results: The patient did not tolerate intravenous fluid management of her hypercalcemia given her cardiac history and furosemide was relatively contraindicated due to concurrent nephrocalcinosis. Eventually, she was given intravenous pamidronate with normalization of calcium levels in 7 days. Her left shoulder pain remained refractory to gabapentin, amitriptyline, topical diclofenac, and topical lidocaine for 2 weeks. However, the pain resolved within 3 days of normalization of her serum calcium levels.

Discussion (relevance): Hypercalcemia in the setting of primary hyperparathyroidism and malignancy are commonly associated with diffuse pain and rheumatic manifestations. However, focal musculoskeletal pain in hypercalcemia from immobility has not been extensively documented in the literature.

Conclusions: Hypercalcemia should be considered as a possible etiology of focal musculoskeletal pain in cases of prolonged immobility.