Intravenous Calcium Gluconate Research Articles

#1807 Use of teriparatide to prevent severe hypocalcemia after parathyroidectomy in dialysis-dependent patients: a feasibility study

Abstract Background and Aims Hungry bone syndrome is a common postoperative complication after parathyroidectomy (PTx) for severe secondary hyperparathyroidism (SHPT). We aimed to conduct a feasibility study to assess the potential impact of teriparatide on the course of postoperative hypocalcemia after PTx in dialysis-dependent patients. Method We performed a randomized controlled pilot study in 20 dialysis-dependent patients with severe SHPT undergoing total parathyroidectomy with autotransplantation of parathyroid tissue. Patients were randomized to receive either 20 mcg teriparatide (Forsteo) subcutaneously on day 1 after surgery in addition to standard postoperative care (n=11) or standard postoperative care alone (n=9). Severe postoperative hypocalcemia was defined as an ionized serum calcium level of less than 0.8 mmol/l during the first 3 days after surgery. Results Patients in the two groups did not differ in terms of pre- and postoperative laboratory data, including PTH, corrected total calcium, ionized calcium and alkaline phosphatase levels – Table 1. Severe hypocalcemia was observed in 6 patients in the teriparatide group (55%) and in 4 patients (44%) in the control group (p=0.99). The proportion of patients with symptoms of hypocalcemia was higher in patients not receiving teriparatide (67% vs 27%, p=0.17), although these differences did not reach statistical significance. All post-PTx patients received standard supplementation according to local protocol, including calcium carbonate 20 gr/day, active vitamin D 2 mcg/day per os, and intravenous calcium gluconate supplementation on demand for symptoms of hypocalcemia (e.g. numbness, tingling, or cramps). Total elemental calcium requirement after surgery (which may serve as a surrogate for the severity of hungry bone syndrome) was higher in patients receiving standard treatment alone (41 [Q1-Q3: 33; 49] grams per hospitalization vs 33 [Q1-Q3: 25; 40] grams in the teriparatide group, p=0.0375) – Fig. 1. The total length of hospital stay was 4 ± 1 days in teriparatide group and 5 ± 2 in control group, p=0.36. Conclusion In dialysis-dependent patients after PTx, we observed a trend towards an alleviation of postoperative hypocalcemia after single injection of teriparatide in addition to routine care. Further studies with larger sample sizes are needed to confirm these preliminary results.

A CASE REPORT ON ATYPICAL PRESENTATION OF CONGENITAL ADRENAL HYPERPLASIA

We report a case of 52-day old infant presented to casualty with complaint of failure to gain weight,10-day history of regurgitation of feeds, poor acceptance of feed and lethargy from one day, not passed urine in last 8hours. On examination baby had tachycardia with signs of dehydration, blood gas shows metabolic acidosis with serum sodium- 124meq/l, serum potassium- 6.2meq/l. A probable diagnosis of failure to thrive with severe sepsis, inborn errors of metabolism (IEM), and CAH was considered and baby was treated with intravenous fluids, antibiotics, calcium gluconate, salbutamol nebulisation and hydrocortisone. Following the above interventions, babys hydration status and ECG changes improved. The diagnosis of CAH was considered as 17- hydroxyprogesterone levels were elevated. Genetic analysis was not done due to patients economic constraints and baby was discharged with oral Hydrocortisone, Fludrocortisone and table salt (Nacl). Currently baby is thriving well with adequate weight gain.

Characteristics and outcomes of cardiac arrest patients with prolonged resuscitation

Background: There is lack of uniformity and consensus amongst the emergency physicians about an appropriate duration of cardiopulmonary resuscitation (CPR) and resuscitative efforts before deciding about termination of resuscitation (TOR) in patients with either out-of-hospital or in the emergency department (ED) non-traumatic cardiac arrests. An ideal duration of resuscitation for those with persistent cardiac arrest has not been determined yet. This study aims to evaluate the resuscitative interventions, patient factors and outcomes associated with prolonged duration of resuscitation in these patients. Methods: A retrospective study conducted in the Emergency Department (ED) of Changi General Hospital, Singapore and included 15 non-consecutive and randomly selected adult patients who either had an out-hospital cardiac arrest (OHCA) or suffered a witnessed cardiac arrest soon after arrival in the ED and were resuscitated further. Results: The median age was 58 years (IQR 51.5–70.5 years), and the median total CPR and resuscitation duration was 46 min (IQR 40–62.5 min). 12 patients sustained ROSC and one had transient ROSC. Ten (10) patients survived to hospital admission from ED and 5 of them underwent emergency angiography from ED. Three patients were discharged from hospital eventually with mRS scores of 0–1. Conclusion: Patients with sustained ROSC were older, had more prevalence of co-morbidities and lesser prevalence of shockable rhythms, received bystander CPR and pre-hospital adrenaline more frequently, had longer total duration of CPR and a larger proportion were administered intravenous calcium gluconate during ED resuscitation.

Prophylactic efficacy of 400 vs. 200 mg/kg /day calcium gluconate to prevent neonatal hypocalcemia

Background Serum calcium is at its lowest level within 24–48 hours after birth, rendering the neonate vulnerable to hypocalcemia. In our center, despite prophylactic administration of 200 mg/kg/day calcium gluconate, the prevalence of neonatal hypocalcemia remains high.
 Aim To determine the prophylactic efficacy of 400 vs. 200 mg/kg/day calcium gluconate in preventing neonatal hypocalcemia.
 Methods A randomized clinical trial with a pre- and post-test experimental design was done on neonates who fasted or received only minimal enteral feeding. Subjects were randomized to receive either 400 mg/kg/day (intervention group) or 200 mg/kg/day (control group) of intravenous calcium gluconate. We compared serum ionized calcium levels on the first day of admission before calcium gluconate administration and on the third day of hospitalization between the intervention and control groups.
 Results The median ionized calcium levels in the intervention vs. control group before calcium gluconate administration was 1.16 (range 0.4-2.4) mmol/L vs. 1.15 (range 0.6-4.5) mmol/L , respectively (P=0.561). After three days of calcium gluconate administration, the median ionized calcium level was 1.19 (range 0.7-1.45) mmol/L vs. 1.19 (range 0.68-4.6) mmol/L in the intervention vs. control group, respectively (P=0.828). The difference in pre- vs. post-administration ionized calcium levels was significant within the intervention group (P=0.032), but not within the control group (P=0.128).
 Conclusion Prophylactic intravenous calcium gluconate at 400 mg/kg/day was not more effective in preventing neonatal hypocalcemia than 200 mg/kg/day.

FRI595 Two Cases Of Severe Symptomatic Hypocalcemia Secondary To Vitamin D Deficiency Diagnosed Within The Same Week

Abstract Disclosure: F.I. Cooper: None. U. Jonsdottir: None. G. Guadalupe Rios: None. N. Vyas: None. S. Gurnurkar: None. Background: Vitamin D is a fat-soluble vitamin that plays a significant role in intestinal calcium absorption. Humans acquire vitamin D through sun exposure and diet, though few foods naturally contain vitamin D in the amount needed to prevent deficiency. Vitamin D deficiency can result in nutritional rickets, which may present with impaired growth, weakened bones, dental abnormalities, and fractures secondary to decreased calcium absorption. Hypocalcemia can lead to a wide variety of clinical manifestations from mild symptoms such as irritability, tremors, and muscle cramps to life threatening seizures and arrhythmias. Case: This case series describes two children presenting to our pediatric emergency department within the same week with severe hypocalcemia secondary to profound vitamin D deficiency. The first was a 2-year-old female with prior medical history of 29-week prematurity who presented with a first time generalized tonic clonic seizure. She had a limited diet that consisted mostly of non-fortified almond milk. As an infant, she was on breast milk but did not receive vitamin D supplementation. On presentation, she was noted to have exam findings and radiographic evidence of rickets. The second was a 13-year-old male with history of non-verbal autism presenting with one month of diarrhea, agitation, and progressive leg pain. The patient was described as a picky eater and spent minimal time outdoors. Both children were found to have severe hypocalcemia (6.6 mg/dL and 4.8 mg/dL, respectively) in the setting of vitamin D deficiency (vitamin D-25 6.8 ng/dL and 4.9 ng/dL, respectively). They were successfully treated acutely with intravenous calcium gluconate bolus (one dose of 495 mg and three 2,000 mg) and oral calcium, with normalization of ionized calcium levels and improvement of symptoms. They were treated long-term with oral calcium, calcitriol, and vitamin D supplementation. Conclusion: Vitamin D deficiency should be considered in severe symptomatic hypocalcemia in children. Vitamin D supplementation is necessary in all breast-fed babies and a large proportion of other children not meeting vitamin D requirements through diet and sun exposure. Presentation: Friday, June 16, 2023

Clinical profile and outcome of patients of common krait bite with features of neurotoxic envenomation, treated with intravenous calcium gluconate infusion in conjunction with AVS, a tertiary care center-based study

Background: Snake bite is one of the most neglected diseases in South East Asian region. Common Krait (CK) (Bungarus caeruleus) is the deadliest snake found in the dry zones of India. With the polyvalent anti-venom serum (AVS) remaining the cornerstone of treatment of neurotoxic snake envenomation, there is no universally accepted treatment for CK envenomation-associated neuroparalysis, except supportive measures. Aims and Objectives: Our study was conducted to describe the epidemiology, define clinical features, study outcome, and apparent efficacy of calcium gluconate in preventing or reversing neuromuscular paralysis with respiratory failure in CK bite patients. Materials and Methods: This study is a prospective observational study done on 52 CK bite patients. Patients were enrolled according to inclusion and exclusion criteria and were treated with AVS and calcium gluconate infusion according to National Standard Guideline, 2016. Patients developing severe respiratory muscle paralysis were offered mechanical ventilation. Results: Patients developed ptosis and dysphagia, pain abdomen, cyanosis, paralysis of jaw and tongue, perioral numbness, altered sensorium, dysphonia, ophthalmoplegia, and paradoxical breathing. 21.15% of patients developed respiratory failure and needed ventilator support with average critical care unit stay of 3 days and average stay on a ventilator of 2 days. 3 patients expired (case fatality rate 5.77%). The average hospital stay was 3.33 days. Conclusion: Our study shows that early intervention in patients of CK bite with neurotoxic envenomation, with calcium gluconate infusion, leads to less mortality and morbidity compared to other relevant studies. Further large-scale studies are required for better understanding and implementation.

Fahr's syndrome with hypoparathyroidism, thrombocytopenia, and seizure: a rare case report.

A 32-year-old male was brought with a repeated history of twitching of hands, tingling sensation, and uncontrolled seizure despite medications. Computed tomography findings showed bilateral basal ganglia, cerebellar dentate nuclei, and subcortical cerebral white matter calcifications. Laboratory studies revealed reduced levels of calcium, parathyroid hormone, and thrombocyte count. Based on these investigations Fahr's syndrome probably due to hypoparathyroidism with thrombocytopenia was diagnosed. The patient was initially treated with intravenous calcium gluconate and platelet transfusion followed by oral calcium supplementation. Fahr's syndrome due to hypoparathyroidism should be suspected in any patient with neurological symptoms and hypocalcemia. Seizures in the patient of Fahr's syndrome with thrombocytopenia could be very detrimental due to the risk of intracranial hemorrhage. Hence, treatment should be started as early as possible.

Prevention of Acute Respiratory Failure Due to Administration of Polymyxins by Intravenous Calcium Gluconate in Critically Ill Patients for Treating Carbapenem Resistant Infections in Acute Medicine Unit: A Quality Improvement Project (Qip)

Background: Polymyxin B and colistin are most potent antibiotics for treating carbapenem resistant infections due tomultidrugs resistant organisms that are currently rising remarkably and alarm signs for global health. These are last resorts options for bacteremia during crisis time when pathogens are only sensitive to polymyxins. Most common life threatening complication is respiratory muscle paralysis due to neuromuscular blockage that lead to apnea, acute type 2 respiratory failure and death. Main aim of this quality Improvement project (QIP)was to demonstrate therapeutic effectiveness and outcomes of I/V calcium gluconate during administration of polymyxins. Methods: This QIP was conducted at acute medicine and HDU of a tertiary care hospital for 2 months in Bangladesh. Patients who got I/V calcium gluconate with polymyxins in January and February, 2023 were compared with similar data without calcium gluconate for prior 4 months. Data analysis and interpretation done by unpaired t test. Results: Primary outcome shows statistically significant decrease dintubation and mechanical ventilation due to sudden respiratory failure and ICU transfer after getting I/V calcium gluconate during polymyxins(30.8%,n=13 and 88.9% ,n=9 and p= <0.005). Conclusion: This study showsstrongly visible positive outcome in prevention of acute respiratory failure by polymyxins in critically ill patients. We feel that all physicians may practice this study in acute medicine and critical care setup. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 216

Abstract #1406692: A Case of Anaplastic Thyroid Carcinoma and Hypocalcemia: Should We Be Monitoring for Hypocalcemia?

Anaplastic thyroid carcinoma is one of the most aggressive and fatal forms of cancer. We present a patient with anaplastic thyroid carcinoma who developed hypocalcemia after diagnosis. A 77-year-old female with a history of hypertension and DM2 presented to the hospital for difficulty breathing and neck fullness for 2 weeks. Upon arrival, she developed stridor and was emergently intubated. Blood pressure was 155/75 mmHg, pulse was 80 beats per minute and respiratory rate 18 per minute on mechanical ventilation. A firm and diffusely enlarged thyroid was palpated on examination with difficulty discerning thyroid borders. CT scan revealed diffuse heterogenous enlargement of the thyroid measuring 43x40mm, a large mass of the right lobe with extracapsular extension, and invasion of surrounding structures. Initial admission labs showed TSH 0.010UIU/mL (0.35-5.5 UIU/mL), free T4 2.56 ng/dL (0.9-1.8 ng/dL), calcium 8.7mg/dL (8.6-10.4 mg/dL), magnesium 3.1mg/dL (1.8-2.5 mg/dL), phosphorus 4.9mg/dL (2.5-4.5 mg/dL), and creatinine 1.1mg/dL (0.50 - 1.20 mg/dL). She was started on high dose steroids for airway edema, which was continued for biochemical hyperthyroidism. A biopsy was positive for anaplastic thyroid carcinoma, and she was started on paclitaxel and carboplatin. On day 7, her corrected calcium dropped to 7.9mg/dL and ionized calcium was 3.72mg/dL (<4.60 or >5.10 mg/dL). PTH level was 61.68pg/mL (9-75 pg/mL) and 25OH vitamin D was 10.3ng/mL (25-80 ng/mL). She was given 1g of intravenous calcium gluconate and began daily calcium 500mg twice daily and cholecalciferol 5000IU daily. Genomic testing was positive for BRAF and targeted therapy with dabrafenib and trametinib was initiated. After 23 days of BRAF targeted therapy, a repeat CT showed radiographic improvement of the thyroid mass, measuring 33x20mm. Calcium levels improved to 9.8mg/dL. Repeat TSH was 0.086UIU/mL and free T4 was 0.730ng/dL and she was started on levothyroxine supplementation. She was transferred to a long-term care facility a few months later with plans for repeat blood work but ultimately passed away 3 months after initial diagnosis. The cause of hypocalcemia in this case is likely multifactorial. She was a critically ill patient with significant vitamin D deficiency, which can be contributing factors. However, the normal PTH level suggests that there may have been some degree of parathyroid dysfunction. Mechanisms that have been proposed for this are mass effect or tumor infiltration from thyroid cancer. Calcium levels should be checked upon diagnosis of anaplastic thyroid cancer and monitored closely throughout the clinical course.

Denosumab-induced hypocalcemia post bariatric surgery—a severe and protracted course: a case report

BackgroundDenosumab is known to cause abnormalities in calcium homeostasis. Most of such cases have been described in patients with underlying chronic kidney disease or severe vitamin D deficiency. Previous bariatric surgery could also contribute to hypocalcemia and deterioration in bone health.Case presentationWe present a case of a 61-year-old Malay female with worsening bilateral limb weakness, paresthesia, and severe carpopedal spasm a week after receiving subcutaneous denosumab for osteoporosis. She had a history of gastric bypass surgery 20 years ago. Post gastric bypass surgery, she was advised and initiated on lifelong calcium, vitamin D, and iron supplementations that she unfortunately stopped taking 5 years after surgery. Her last serum blood tests, prior to initiation on denosumab, were conducted in a different center, and she was told that she had a low calcium level; hence, she was advised to restart her vitamin and mineral supplements. Laboratory workup revealed severe hypocalcemia (adjusted serum calcium of 1.33 mmol/L) and mild hypophosphatemia (0.65 mmol/L), with normal magnesium and renal function. Electrocardiogram showed a prolonged QTc interval. She required four bolus courses of intravenous calcium gluconate, and three courses of continuous infusions due to retractable severe hypocalcemia (total of 29 vials of 10 mL of 10% calcium gluconate intravenously). In view of her low vitamin D level of 33 nmol/L, she was initiated on a loading dose of cholecalciferol of 50,000 IU per week for 8 weeks. However, despite a loading dose of cholecalciferol, multiple bolus courses, and infusions of calcium gluconate, her serum calcium hovered around only 1.8 mmol/L. After 8 days of continuous intravenous infusions of calcium gluconate, high doses of calcitriol 1.5 μg twice daily, and 1 g calcium carbonate three times daily, her serum calcium stabilized at approximately 2.0 mmol/L. She remained on these high doses for over 2 months, before they were gradually titrated down to ensure sustainability of a safe calcium level.ConclusionThis case report highlights the importance of screening for risk factors for iatrogenic hypocalcemia and ensuring normal levels before initiating denosumab. The patient history of bariatric surgery could have worsened the hypocalcemia, resulting in a more severe presentation and protracted response to oral calcium and vitamin D supplementation.

Iatrogenic calcinosis cutis in a preterm infant.

Extravasation phlebitis over the right forearm of a preterm newborn persisted beyond 3 weeks of limb care. The initial swelling evolved into a firm, non-tender, non-erythematous induration. The newborn was born as a singleton preterm birth at 32 weeks of gestation with a birth weight of 2.1 Kg (81 percentile) due to antepartum hemorrhage in a primigravida mother. The chart review suggested intravenous calcium gluconate infusion at 80 mg/kg per day for 2 days because of low ionized calcium (0.70 mmol/L) and seizures on day 2 of life.

PSAT189 Severe Hypocalcemia and Hypophosphatemia Associated with Denosumab use in a Chronic Myeloid Leukemia Patient on Imatinib

Abstract Background Hypocalcemia and hypophosphatemia are known side effects of Denosumab, especially in presence of risk factors including underlying chronic kidney disease, osteoblastic metastasis, high bone turnover states, vitamin D deficiency and preexisting hypocalcemia. We report a unique case of prolonged severe hypocalcemia and hypophosphatemia in a patient with CML on Imatinib, treated with Denosumab for osteoporosis. Clinical case A 73-year-old lady with history of CML, on Imatinib for 4 years and osteoporosis with a chronic L1 compression fracture treated with her second dose of Denosumab 3-months back, presented with complaints of numbness and tingling involving the entire body. Labs revealed severe hypocalcemia (calcium 5.6 mg/dL, ionized calcium 2.93 mg/dL), severe hypophosphatemia, (phosphorus of 0.5mg/dL) and a low normal magnesium level of 1.5mg/dL, with normal ALP, liver and kidney function parameters. Of note she had normal calcium, phosphorus and vitamin D levels before receiving denosumab. Further work-up revealed an elevated PTH level of 241 pg/mL, normal 25 hydroxy vitamin D level of 26.0 ng/ml, slightly low 1,25 (OH) vitamin D of 16pg/ml and an elevated FGF 23 of 299RU/mL (normal &amp;lt;180RU/mL). Her calcium and phosphorus levels remained suboptimal despite treatment with up to 24 grams of calcium carbonate supplementation daily, K-phos 1 packet QID and calcitriol 0.25 mcg TID. 24-hour urine calcium and phosphorus levels were low at 4mg/day and 0.2mg/day respectively. Fractional excretion of phosphate was 13.63%, suggesting renal phosphorus wasting, likely from an elevated FGF23. Bone scan showed no metastatic lesion. After discussion with oncology, Imatinib was held inpatient and she was started on intravenous calcium gluconate infusion, and continued on Calcitriol, vitamin D3 and K-phos supplementation. After receiving almost 18gm of calcium gluconate intravenously over 2 days, her hypocalcemia and hypophosphatemia resolved with improvement in symptoms. Conclusion Hypocalcemia is a recognized adverse effect of Denosumab that is seen in patients with underlying risk factors. Emerging data now suggests the deregulatory effect of long term Imatinib therapy on bone formation by inhibition of osteoclastic activity along with transient increase in osteoblastic activity leading to retention and sequestration of calcium and phosphate in bone, resulting in hypocalcemia and hypophosphatemia. Ours is the first reported case of severe hypocalcemia and hypophosphatemia observed in a CML patient on Imatinib after receiving Denosumab, with resistance to high dose oral calcium and phosphate supplementation, requiring intravenous supplementation and transient discontinuation Imatinib. The elevated FGF 23 likely played a key role in severe hypophosphatemia. This unique case addresses the prospect of occurrence of severe hypocalcemia and hypophosphatemia in patients on Imatinib receiving Denosumab, while questioning the possibility of potentiation of the osteoclast inhibitory effect of this medication when used in patients on long term Imatinib therapy. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

IT IS NOT ALWAYS CHEMOTHERAPY THAT LYSES THE CELLS: A CASE OF TUMOR LYSIS SYNDROME PRESENTING IN ENDOMETRIAL CANCER AFTER IMMUNOTHERAPY

IT IS NOT ALWAYS CHEMOTHERAPY THAT LYSES THE CELLS: A CASE OF TUMOR LYSIS SYNDROME PRESENTING IN ENDOMETRIAL CANCER AFTER IMMUNOTHERAPY

Effect of Intravenous Calcium Gluconate on Prevention of Post Spinal Hypotension during Spinal Anaesthesia for Caesarean Section: A Randomized Double-Blind Controlled Study.

Calcium, a physiological ion, causes vasoconstriction and has a positive ionotropic action on heart. Its use to prevent post-spinal hypotension has been suggested but never formally evaluated for patients undergoing caesarean section. This study investigated the hemodynamic effects of calcium administration in parturients with the primary aim of comparing the incidence of post-spinal hypotension. Sixty healthy full-term pregnant patients scheduled for caesarean section were randomly allocated to two equal groups to receive either calcium gluconate or normal Saline bolus over 20min by syringe infusion pump under electrocardiography monitoring immediately after the patient was turned supine following spinal anaesthesia. Blood pressure and heart rate were recorded at baseline, and at regular intervals following spinal. Maternal calcium levels were estimated before and after infusion. Neonatal blood gas analysis and calcium level were analyzed. Total mephentermine requirement was recorded in both groups. The heart rate values remained comparable to baseline value in group calcium gluconate while in group normal Saline, it decreased significantly at 8,12 and 16min. Blood pressure decreased significantly as compared to the baseline value from 4min onwards in both the groups. However, it was comparable in the two groups at all time points(0.622). Nineteen patients(63.33%) required mephentermine infusion in group calcium gluconate as compared to 23 patients(76.6%) in group normal Saline for maintenance of systolic blood pressure.(p=0.791) Umbilical venous pH (p=0.038) and partial pressure of carbon dioxide(p=0.038) were significantly better in group calcium gluconate. Calcium used for prophylaxis of hypotension in healthy parturients undergoing caesarean section reduced the vasopressor requirements and total mephenteramine dose, but the difference did not attain statistical significance.

A Term Neonate with Multiorgan Dysfunction, Severe Metabolic Acidosis, and Hyperkalemia.

A Term Neonate with Multiorgan Dysfunction, Severe Metabolic Acidosis, and Hyperkalemia.

Abstract #1161627: Hypoparathyroidism Manifesting a Decade After Thyroidectomy

Postoperative hypocalcemia usually occurs in the first days after surgery and can be the result of dynamic changes in electrolytes after interventions. When accompanied by a low parathyroid hormone (PTH) level, it is considered hypoparathyroidism. 41-year-old female with history of hypertension and multinodular goiter status post total thyroidectomy (16 years prior) presented with full body and jaw stiffness of 1-hour duration. She reported perioral tingling for the last 5 years and bilateral forearm tingling in the past week. She recalled taking calcium supplements for a brief period after surgery and then again 5 years after surgery. She had not taken any supplements for the last 9 years. Examination shows no neck masses or lymphadenopathy, no limb deformities, and positive Chvostek sign. Laboratory showed serum calcium of 5.1mg/dL (8.9-10.7), ionized calcium 0.92mmol/L (1.16-1.32), albumin 3.7g/dL (3.7-4.9), phosphorus 6.0mg/dL (2.5-4.6), magnesium 1.2mg/dL (1.8-2.8), intact PTH 15.9pg/mL (8.7-77.1), and 25-OH vitamin D of 6.5ng/mL (30.0-100.0). Pathology report confirmed removal of only 1 parathyroid gland. She was started on intravenous calcium gluconate; followed by calcium carbonate, calcitriol, magnesium, and ergocalciferol. Two months after, while taking only calcium carbonate, she showed persistent hypocalcemia with serum calcium of 7.4mg/dL, PTH of 14pg/mL. Calcium decreased to 5.9mg/dL when supplements were stopped; increased to 9.5mg/dL after resuming calcium carbonate and calcitriol. The literature describes an incidence of 0% to 6% of permanent hypoparathyroidism following complete thyroid resection. The fragile nature of the parathyroid glands leaves them susceptible to injuries after manipulation. The short half-life of the PTH allows for prompt clinical manifestations of hypocalcemia after thyroidectomy. Rarely, the manifestations can take several years to present, which is known as “late-onset” or “delayed” hypoparathyroidism. It has been hypothesized that this phenomenon is the result of progressive atrophy of the parathyroid glands; others suggest that scar tissue in the glands leads to hypo-vascularization and slowly progressive ischemia. There are 5 case reports of delayed presentation of post-surgical hypoparathyroidism described in the literature. Four out of five cases were reported in women; three of these cases underwent thyroidectomy for thyroid cancer and two of them for multinodular goiter. Most of the cases presented 12-14 years after surgery; symptoms range from muscle cramps and paresthesia to seizures. Our patient may have had parathyroid insufficiency since her thyroidectomy with intermittent manifestations of hypocalcemia with unclear triggers. It is possible this admission was exacerbated by severely low vitamin D levels. She requires long term treatment for hypocalcemia now as parathyroid glands have completely failed. This case also illustrates that patients with permanent hypoparathyroidism should be followed on a yearly basis to ensure medication adherence and they should be warned about ominous manifestations of hypocalcemia in the long term.

Clinical and genetic analysis of pseudohypoparathyroidism complicated by hypokalemia: a case report and review of the literature

BackgroundPseudohypoparathyroidism (PHP) encompasses a highly heterogenous group of disorders, characterized by parathyroid hormone (PTH) resistance caused by mutations in the GNAS gene or other upstream targets. Here, we investigate the characteristics of a female patient diagnosed with PHP complicated with hypokalemia, and her family members.Case presentation and gene analysisA 27-year-old female patient occasionally exhibited asymptomatic hypocalcemia and hypokalemia during her pregnancy 1 year ago. Seven months after delivery, she experienced tetany and dysphonia with diarrhea. Tetany symptoms were relieved after intravenous calcium gluconate supplementation and she was then transferred to our Hospital. Laboratory assessments of the patient revealed hypokalemia, hypocalcemia and hyperphosphatemia despite elevated PTH levels. CT scanning of the brain revealed globus pallidus calcification. Possible mutations in GNAS and hypokalemia related genes were identified using WES, exon copies of STX16 were analized by MLPA and the methylation status of GNAS in three differential methylated regions (DMRs) was analyzed by methylation-specific polymerase chain reaction, followed by confirmation with gene sequencing. The patient was clinically diagnosed with PHP-1b. Loss of methylation in the A/B region and hypermethylation in the NESP55 region were detected. No other mutations in GNAS or hypokalemia related genes and no deletions of STX16 exons were detected. A negative family history and abnormal DMRs in GNAS led to a diagnosis of sporadic PHP-1b of the patient.ConclusionsHypokalemia is a rare disorder associated with PHP-1b. Analysis of genetic and epigenetic mutations can aid in the diagnosis and accurate subtyping of PHP.

Iatrogenic calcinosis cutis in 9-month-old baby boy: a case report

BackgroundCalcinosis cutis is a rare condition, characterized by an accumulation of calcium salts in the skin and subcutaneous tissue. There are several types of this condition, including dystrophic, metastatic, idiopathic, calciphylaxis, and iatrogenic calcinosis cutis. The type related to our case is iatrogenic calcinosis cutis, and one its possible causes is calcium intravenous infusion. Physicians should be aware of this condition when giving calcium infusion.Case presentationHere we report the case of a 9-month-old Arabic - Saudi baby boy, who presented with abnormal movement for 1 day. Upon further investigation, his abnormal movement was found to be a manifestation of hypocalcemia and vitamin D deficiency. He was treated with intravenous calcium gluconate. Later, he had a treatment-related complication of intravenous calcium at the site of venipuncture causing swelling, which was initially soft but progressed to hard, over the left hand. Eventually, he was diagnosed with a case of iatrogenic calcinosis cutis due to intravenous calcium treatment.ConclusionThere are multiple differential diagnoses of calcinosis cutis, as it resembles many other conditions. Careful history-taking, physical examination, and other investigations, such as radiological investigations, will aid in reaching a more accurate diagnosis and, thus, early treatment and intervention. Frequently checking the intravenous line and diluting the intravenous calcium may help reduce the occurrence of iatrogenic calcinosis cutis.

Calcium gluconate infusion is not as effective as dopamine agonists in preventing ovarian hyperstimulation syndrome.

The aim of the study was to compare the effectiveness of calcium gluconate and cabergoline therapy in the prevention of ovarian hyperstimulation syndrome (OHSS). Eight hundred and forty-five women who underwent GnRH antagonist protocol and at high risk for developing OHSS were divided into two groups, those given cabergoline (n=435) or calcium gluconate (n=410). In cabergoline group, 0.5 mg of cabergoline was administered once daily p.o. starting on the day of ovulation trigger and continued until the following 8 days. In calcium gluconate group, intravenous calcium gluconate was administered daily for four days starting on the day of oocyte pickup (OPU). 10 ml of 10% calcium gluconate solution was dissolved in 200 ml of physiological saline and administered by intravenous route within 40 minutes. Infusion was started within the first 30 minutes following the OPU and continued on the 1st, 2nd and 3rd days after OPU. Mild OHSS was developed in 367 (89%) patients receiving calcium gluconate infusion, while 251 patients (57%) in the cabergoline group developed mild OHSS. The frequency of mild OHSS in the calcium group was significantly higher than the cabergoline group (p<.001). Moderate OHSS was observed in 32 people (7.8%) in the calcium gluconate group, while it was observed in 184 people in the cabergoline group (42.3%). Calcium gluconate infusion significantly reduced the development of moderate OHSS compared to cabergoline therapy (p<.001). Severe OHSS developed in 11 patients (2.7%) in the calcium gluconate group, while severe OHSS did not develop in those given cabergoline (0%, p<.001). Clinical pregnancy, live birth and abortion rates were similar in the two groups. When logistic regression analysis was performed, a significant correlation was found between age, BMI, AMH, the number of antral follicle count, OHSS history, paracentesis, progesterone on the day of hCG, 2 PN zygotes, and HbA1c levels and the development of OHSS. No correlation was found between the use of metformin or cetrotide and the development of OHSS. Calcium gluconate treatment is not effective in the prevention of OHSS.

LIFE-SAVER INSULIN: "THE MORE THE BETTER"

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Calcium channel blockers (CCB) are cardiovascular drugs that act on L-type calcium channels. Toxic exposures related to CCB is estimated to be 4.16% of all prescription overdoses. Toxicity leads to peripheral vasodilation, conduction blockade, and reduction in myocardial contractility. Additionally, high doses of CCBs inhibit the release of endogenous insulin and induce a state of hypoinsulinemia. In this state, myocardial cells are unable to uptake glucose for metabolic activity, which can be detrimental in the setting of shock. Treatment of CCB overdose revolves around administration of fluids, calcium, vasopressors, and ionotropic agents. Furthermore, cases involving cardiogenic shock should consider prompt addition of hyperinsulinemic-euglycemic therapy (HIET). The mechanisms by which HIET treats CCB overdose is theorized to be due to improved glucose uptake by myocardial cells, a concentration dependent ionotropic effect and systemic vasodilation. CASE PRESENTATION: A 41-year-old male with hypertension and major depressive disorder presented in shock after he intentionally ingested 600mg amlodipine in combination with alcohol. Despite aggressive initial measures with intravenous fluids, glucagon, calcium gluconate and high-dose vasopressor therapy ((nor-)epinephrine, vasopressin and angiotensin II), his condition worsened. He was intubated and started on HIET (bolus of intravenous insulin 1unit/kg followed by an infusion which was steadily increased to 8units/kg/hr). A continuous infusion of D25W was administered to maintain euglycemia and plasmapheresis was started to aid in the removal of amlodipine.The patient's course was further complicated by acute renal failure which led to overt volume overload. Continuous renal replacement therapy (CRRT) and eventually intermittent hemodialysis were started. Ultimately, he was gradually weaned off vasopressor support over 7 days while on HIET. DISCUSSION: The presented case highlights the importance of HIET in treating refractory cardiogenic shock caused by CCB overdose. Concomitant renal failure can be additive to the patient's clinical picture due to high quantities of intravenous volume needed with HIET. To our knowledge this is the first case to successfully utilize prolonged HIET with CRRT for CCB overdose. This case demonstrates that there may be promise in the utility of prolonged HIET for cases of complex CCB overdose with refractory shock. Due to lack of large sample sizes and randomized controlled studies, consideration for prolonged therapy or its role in renal failure should be given on a case-by-case scenario. CONCLUSIONS: Prolonged HIET is a promising treatment for cases of complex CCB overdose with refractory shock. REFERENCE #1: Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 34th Annual Report. Clin Toxicol (Phila) 2017;55:1072–252 REFERENCE #2: Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. BrJ Clin Pharmacol 2016;81:453–61 DISCLOSURES: No relevant relationships by Shijo Benjamin, source=Web Response No relevant relationships by Md Islam, source=Web Response No relevant relationships by Maulin Patel, source=Web Response No relevant relationships by Mirja Wirtz, source=Web Response