Hypercalcaemic crisis as presentation of Addison's disease.

Fatal irreversible hypercalcaemia in breast cancerOsteolytic bone metastases may cause excessive release of calcium from the skeleton and result in progressive, fatal hypercalcaemia.1 2 Oestrogen treatment for metastatic disease may precipitate this.3We describe two patients who developed fatal hypercalcaemia within days of starting oestrogen treatment. Case reportsCase 1-A 73-year-old woman was admitted to hospital with carcinoma of the breast, lymph node and liver metastases, and bilateral pleural effusions.She had no pain, and marrow aspirate and skeletal x-ray appearances were normal, but the bone scan showed multiple bone metastases.Serum calcium was 2-4 mmol/l (9 6 mg/100 ml) and serum alkaline phosphatase 145 IU/1.Ethinyloestradiol 0 3 mg/day caused nausea, malaise, and drowsiness but the serum calcium remained normal (2-15 mmol/l; 8-8 mg/100 ml).She recovered after withdrawal of the hormone, which was restarted at 0-1 mg/ day.Three days later she was asymptomatic but her serum calcium had risen to 4 76 mmol/l (19 mg/100 ml).Oestrogen treatment was stopped but despite a diuresis of 5 1 in 24 hours, intramuscular hydrocortisone 100 mg six- hourly, and intravenous mithramycin 1 mg, the serum calcium rose to 5-5 mmol/l (22 mg/100 ml) and she died (see figure).Necropsy showed metastatic deposits in viscera, lymph nodes, ovaries, and bone marrow.Parathyroid glands were normal.Case 2-In 1971 a 57-year-old woman had a mastectomy for carcinoma of the breast.From 1974 to August 1975 she was treated with nandrolone for bone metastases with good symptomatic results.In November 1975 she was admitted to hospital for further hormone treatment.Serum calcium was 2-25 mmol/l (9 mg/100 ml) and serum alkaline phosphatase over 500 IU/1.X-ray examination showed widespread osteolytic metastases, and bone Case I Case 2 50 Urinary hydroxyproline 2 Uri nary calcium E40