S3553 From Heavy Menstrual Bleeding to Hypercalcemia-Induced Pancreatitis: The Unseen Connection

Introduction: I present a case with acute pancreatitis from hypercalcemia due to excessive chalk ingestion due to pica, driven by heavy menstrual bleeding from uterine leiomyoma. Case Description/Methods: A 51-year-old African-American woman with newly diagnosed diabetes mellitus type 2, presented with altered mentation, appeared pale, generalized weakness, vomiting, and increasing lethargy over the last 4 days. On assessment, she was found to be hypotensive, tachycardic, and hyperglycemic with a blood glucose level of 679 mg/dL. Laboratory results revealed elevated calcium of 25.4 mg/dL, lipase- 1739 U/L, and an ABG showing metabolic alkalosis. Imaging of the head and chest showed no acute findings, but abdominal/pelvic computed tomography revealed pancreatitis and a large pelvic mass consistent with uterine leiomyoma. Subsequently, she was admitted to the intensive care unit and received 2 total hemodialysis sessions, fluids, and calcitonin with eventual resolution of hypercalcemia. Prior to the resolution, an extensive workup for hypercalcemia was obtained. This included a low PTH level of 5.9 pg/mL and low phosphate levels of 1.5 mg/dl and other tests were unremarkable- ruling out malignancy, sarcoidosis, and parathyroid disorders. However, the complete blood count revealed a Hgb of 6.5 g/dl, MCV of 63, iron level of 8 µg/dL, normal ferritin, and reticulocyte levels, and a blood smear showing microcytic anemia. She also denied the use of thiazides, antacids, and vitamin D supplements. Once the encephalopathy improved, patient was asked if she consumed anything unusual, to which she revealed that she ate multiple bags of chalk every day. She eventually received intravenous iron and was discharged with iron supplements and a follow-up with Gynecology. Discussion: The triad of hypercalcemia, metabolic alkalosis, and renal impairment mimics milk-alkali syndrome, usually from excess calcium supplements or antacids. However, this patient developed hypercalcemia which induced pancreatitis from consuming large amounts of chalk, driven by pica secondary to iron deficiency anemia due to heavy menstrual bleeding from uterine leiomyomas. Chalk, composed mainly of calcium carbonate, can elevate serum calcium levels similarly to antacids, but its role as a cause of hypercalcemia is often overlooked. We suggest considering chalk as a potential etiology during history taking, especially if the patient has pancreatitis or exhibits hypercalcemia on lab results.