An uncommon cause of apparent life-threatening event

Abstract

An apparent life threatening event (ALTE) in infancy is a common reason for presentation to the emergency department (ED). We report a case of a breast-fed infant who presented with an ALTE secondary to hypocalcemia from undiagnosed rickets. Case Report: A 9-month-old girl was brought to the ED because she stopped breathing. The parents reported that she stopped breathing for more than 20 seconds and was gasping for air. During the event, she became unresponsive and her eyes rolled back. There was a history of cough and nasal congestion with subjective fever for two days. Further questioning revealed that over the last few months, she had had episodes of 'gasping', and 'strange noisy breathing sounds.' Her mother reported an 'odd cough' for several months. The baby had been exclusively breastfed and was noted by her mother to be feeding well. No solid foods had been introduced to the patient. The past medical history was significant for developmental delay. The patient was born full-term via normal spontaneous vaginal delivery. The pregnancy, however, had been complicated by oligohydramnios. The parents reported no family history of vitamin D deficiency, rickets or seizure disorder. A chest radiograph showed flaring of the costochondral junctions consistent with rickets. Her vitamin D 25-0H level was 5 ng/mt, (20-100) and D3 level was less than 5 ng/ml, Conclusion: Hypocalcemia is a difficult to diagnose in infants because there may present with a wide range of non-specific clinical symptoms, or they may be asymptomatic. It is important for the emergency physician to recognize the association of hypocalcemia with ALTE in infants. Rickets is a re-emerging health problem in infants and children. Physicians should therefore maintain a high index of suspicion for hypocalcemia especially in a breast-fed infant. We suggest including serum calcium level as part of the evaluation of ALTE.