Severe hypercalcemia in a patient with end-stage liver disease

Severe hypercalcemia is commonly attributed to malignancy. Maintaining a broad differential diagnosis is important in patients with end-organ disease. We present a 47-year-old man with end-stage alcoholic cirrhosis who presented to the outpatient clinic with profound hypercalcemia. His albumin-corrected calcium was 16.8 mg/dL (SI: 4.2 mmol/L) (reference range, 8.5-10.1 mg/dL [SI: 2.1-2.5 mmol/L]) and he had an acute kidney injury. Laboratory evaluation revealed a suppressed parathyroid hormone. Imaging excluded malignancy. Workup for adrenal insufficiency suggested partial secondary disease as a contributing factor. With aggressive fluid hydration and corticosteroids, his symptoms and biochemistry improved. His calcium remained mildly elevated consistent with ongoing cirrhosis-related hypercalcemia. This case underscores the importance of maintaining a broad differential for severe hypercalcemia and considering cirrhosis itself as an etiologic factor.