Betel Nut Chewing: An Unrecognized Cause of Milk Alkali Syndrome

ABSTRACT Objective: To describe an uncommon case of milk alkali syndrome from betel nut chewing. A 60-year-old Pakistani woman was referred to the Endocrinology Clinic for hypercalcemia. She reported a history of type 2 diabetes mellitus, hypothyroidism, anxiety, and renal stones. She denied symptoms of hypercalcemia. However, her serum calcium levels were noted to be above the upper end of reference range but consistently below 11 mg/dL. She was noted to have alkalosis and low parathyroid hormone levels, despite a normal renal function. A 24-hour urine stone profile revealed high-normal urine calcium and low urine citrate levels. Upon further history, it was noted that she avidly chewed betel nut up to 15 times a day, along with lime paste and tobacco paste. She was physically and psychologically addicted to this process. She was also taking calcium supplementations. On exam, she was noted to have dark pigmentation of her tongue from chronic use of lime paste and retention of betel nut in her mouth. Methods: A MEDLINE search was performed with the keyword ‘milk-alkali syndrome’ using the PubMed search engine. All relevant English-language articles were reviewed. Results: Milk alkali syndrome was highly suspected to be the cause of her hypercalcemia. Patient was encouraged to decrease the frequency of betel nut chewing and discontinue the calcium supplements, along with fluid hydration. Conclusion: Her calcium levels eventually decreased to the reference range after 3 months of discontinuation of her calcium supplements. She is also trying to decrease the frequency of betel nut chewing. Abbreviations: MAS = milk alkali syndrome PTH = parathyroid hormone