title: Bisphosphonate treatment of tumor-induced hypercalcemia in a toddler: case report and review of related literature.
abstract: OBJECTIVE
  To describe the initial manifestations and treatment of parathyroid hormone-related peptide (PTH-rP)-induced hypercalcemia in a toddler with a malignant rhabdoid tumor.
  
  
  METHODS
  We report a case of a 2-year-old boy presenting with poor appetite, lethargy, and a 1.5-kg weight loss during a 2-week period. On examination, the child was found to have a right upper quadrant abdominal mass. Laboratory studies revealed severe hypercalcemia. We review the patients' clinical course and management of hypercalcemia.
  
  
  RESULTS
  Initial evaluation revealed no cardiovascular instability. An abdominal mass was identified on physical examination. Initial laboratory studies revealed elevated levels of total and ionized calcium, low phosphorus, microcytic anemia, and elevated erythrocyte sedimentation rate. Saline diuresis with furosemide was begun. Abdominal ultrasonography revealed a large right renal tumor. Because of refractory hypercalcemia, intravenously administered bisphosphonate was used. Within 12 hours after bisphosphonate infusion, the serum calcium level declined from 14.9 mg/dL to 10.9 mg/dL. The furosemide dose was decreased and finally discontinued 2 days after bisphosphonate administration. Because of development of a femoral thrombosis, definitive surgical intervention was delayed. During that time, serum calcium levels again increased and necessitated administration of a second bisphosphonate dose. At surgical treatment, a right renal tumor was identified, and frozen section pathology revealed a rhabdoid tumor. After tumor resection, calcium levels were stable. Other laboratory studies performed at admission revealed suppressed PTH, normal vitamin D and calcitonin levels, and elevated PTH-rP.
  
  
  CONCLUSIONS
  Hypercalcemia in a toddler is a rare event and can be attributable to humoral factors released by malignant tumors. Hypercalcemia in the pediatric population can be treated effectively with bisphosphonates when conservative measures fail.
authors.affiliation: Division of Pediatric Endocrinology, Women's and Children's Hospital of Buffalo, The State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, New York 14222, USA.
authors.forename: Lucy D
authors.initials: LD
authors.lastname: Mastrandrea
authors.forename: Christine H
authors.initials: CH
authors.lastname: Albini
mesh_terms: D002675:Child, Preschool; D003937:Diagnosis, Differential; D004164:Diphosphonates / Q000627:therapeutic use*; D006801:Humans; D006934:Hypercalcemia / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology*; D007680:Kidney Neoplasms / Q000150:complications* / Q000601:surgery; D008297:Male; D044162:Parathyroid Hormone-Related Protein / Q000009:adverse effects; D018335:Rhabdoid Tumor / Q000150:complications* / Q000601:surgery
chemical_list: D004164:Diphosphonates; D044162:Parathyroid Hormone-Related Protein