Practice Lesson of the week

Milk alkali syndrome without the milk

BMJ 2007; 335 doi: (Published 23 August 2007) Cite this as: BMJ 2007;335:397
  1. Michail Kaklamanos, senior house officer,
  2. Petros Perros, consultant endocrinologist
  1. Michail Kaklamanos, Petros Perros Endocrine Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN
  1. Correspondence to: petros.perros{at}
  • Accepted 11 April 2007

Milk alkali syndrome is easily missed and should be considered in all patients who present with hypercalcaemia

Milk alkali syndrome is the third commonest cause of hospital admissions for hypercalcaemia,1 2 but the diagnosis is often missed.2 3 4 5 Misdiagnosis can lead to unnecessary and potentially invasive investigations and inappropriate treatment

Case report

A 76 year old woman was referred to a gastroenterology outpatient clinic with altered bowel habit. She had a six month history of alternating constipation and diarrhoea, and she admitted to polydipsia, polyuria, and nocturia. She had no nausea, vomiting, abdominal pain, or weight loss. Her regular prescriptions included salbutamol inhaler, a calcium channel blocker, and ibuprofen for chronic obstructive pulmonary disease, hypertension, and osteoarthritis. She had a history of dyspepsia caused by gastric erosions noted on gastroscopy. She denied taking vitamin supplements or other over the counter medications. Clinical examination was unremarkable, but routine investigations showed hypercalcaemia (table). She was admitted for immediate treatment with intravenous fluids and intravenous infusion of disodium pamidronate 90 mg. On the second day after admission, her serum calcium concentration was normal. …

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