Intravenous Calcium Gluconate Research Articles

8541 Hypocalcemia In Setting Of Hypoparathyroidism And Gastric Bypass

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. Background: Hypocalcemia secondary to hypoparathyroidism is a known complication for patients who undergo thyroidectomy. (1) Additionally, patients who undergo bariatric surgery are similarly at risk for developing hypocalcemia. (2) Clinical Case: 52-year-old female with past medical history of thyroid carcinoma status post total thyroidectomy complicated by post operative hypoparathyroidism and history of gastric bypass presented to the hospital with paresthesia and fatigue. On presentation, calcium measured at 6.9 mg/dL, EKG showed Qtc prolongation at 503. Physical exam was positive for Chvostek sign and Trousseau sign. The patient received 1 g of intravenous calcium gluconate and was admitted to medicine for management of symptomatic hypocalcemia. Calcium initially improved to 8.2 mg/dL with a subsequent drop to 7.5 mg/dL. An additional 1 g of intravenous calcium gluconate was administered, calcium then corrected to 8.0 mg/dL, symptoms and Qtc prolongation resolved. The patient endorsed compliance with daily calcium supplementation of oral calcitriol prior to presentation. Prior to discharge, calcitriol dosage was increased, and patient was instructed to follow up calcium levels in one week outpatient with endocrinologist. Conclusion: Bariatric surgery, specifically gastric bypass or Roux-en-Y bypass reduces absorption of vitamin D and calcium as the primary sites for absorption are bypassed. (3) Although not commonly studied, severe hypocalcemia is linked to an increased risk for development of serious cardiac arrhythmias. (4) This emphasizes the importance of close calcium monitoring in patient with history of bariatric surgery and hypoparathyroidism.

6871 Hungry Bone Syndrome After Parathyroidectomy in End-Stage Kidney Disease: A Case Report Analysis

Abstract Disclosure: R. Rani: None. C. Mullarkey-desapio: None. Introduction: Hungry Bone Syndrome (HBS) is a rare yet severe complication following parathyroidectomy, characterized by pronounced hypocalcemia subsequent to a rapid decline in parathyroid hormone (PTH) levels. Renal hyperparathyroidism (RHPT) carries a heightened risk of HBS compared to primary hyperparathyroidism (PHPT), with prevalence varying from 15% to 25% in PHPT to as high as 75-92% in RHPT. This elevated risk in RHPT is attributed to chronically elevated PTH levels, both in terms of duration and intensity as compared to PHPT. Preoperative predictors for HBS occurrence and severity include younger age, larger gland size, lower preoperative calcium levels, elevated bone turnover markers, and the magnitude of PTH elevation. Case Report: We present a case of a 36-year-old female with End-Stage Renal Disease (ESRD) requiring dialysis, complicated by renal osteodystrophy and a radial fracture, unresponsive to medical therapy, who was admitted for parathyroidectomy. Preoperative labs revealed calcium at 8.3 mg/dL, phosphate at 4.1 mg/dL, alkaline phosphatase (ALP) at 797 IU/L, and an extremely elevated parathyroid hormone (PTH) level at 4139 pg/ml. Within 24 hours of parathyroidectomy (three and a half glands were removed, the largest weighing 0.7gm), her PTH levels declined to the 130s, accompanied by symptomatic hypocalcemia (calcium 6.5mg/dL). Initial management involved intravenous calcium gluconate and subsequent high-dose oral calcium (up to 10-16gm daily) with Calcitriol 1 mcg twice daily. Despite repletion, her calcium levels remained low on postoperative day 4 (calcium 6.8mg/dL, phosphate 1.9 mg/dL, magnesium 1.7mg/dL) with PTH at 131 pg/ml, confirming Hungry Bone Syndrome. After seven days of aggressive intravenous and oral calcium supplementation with high-dose Calcitriol, she was discharged with a calcium level of 8.9mg/dL. Discussion: Management of HBS following renal hyperparathyroidism surgery presents significant challenges due to associated comorbidities and other electrolyte abnormalities, with limited literature providing guidance on prevention and management. Our case demonstrated that early suspicion and aggressive management improved patient outcomes. Suspecting HBS in high-risk individuals and initiating interventions pre and post-surgery, including pre-treatment with calcitriol, bisphosphonates, and early aggressive intravenous calcium supplementation post-surgery, could potentially reduce morbidity and length of hospital stay. Presentation: 6/1/2024

8216 When calcium makes you breathless, exploring hypocalcemia-induced bronchospasm

Abstract Disclosure: K.N. Pereira: None. V. Sundaram: None. H.S. Sreemantula: None. When calcium makes you breathless, exploring hypocalcemia-induced bronchospasm Hypocalcemia, characterized by low levels of serum calcium, is an uncommon yet potentially life-threatening condition with various clinical manifestations. This case report delves into an unusual manifestation of hypocalcemia-induced bronchospasm in a 54-year-old male with an extensive medical history, including chronic kidney disease, insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, ascending aortic aneurysm and hyperthyroidism. Despite multiple interventions in the emergency department like nebulized bronchodilators and intravenous steroids, his 4 day misery of respiratory distress persisted. Physical exam was notable for tachypnea, audible wheezing, and accessory muscle use for respiration. Work up was negative for infectious and pulmonary causes including asthma or chronic obstructive pulmonary disease. However, his laboratory results unveiled severe hypocalcemia (calcium: 5.7 mg/dL), elevated creatinine (Cr: 5.90), and blood urea nitrogen (BUN: 64), profound vitamin D deficiency with a 25-OH vitamin D level below 7 and elevated parathyroid hormone (PTH- 375.7). He was ultimately diagnosed with hypocalcemia-induced bronchospasm as intravenous calcium gluconate administration led to gradual respiratory improvement. This case highlights the necessity of considering hypocalcemia-induced bronchospasm in respiratory distress differentials, even in patients with concurrent asthma or COPD histories. The rarity of this presentation, coupled with the patient's complex medical history, underscores diagnostic challenges, necessitating a high index of suspicion. Timely hypocalcemia assessment and calcium replenishment are vital in averting mortality linked to this unusual manifestation. Clinicians must exercise caution to prevent misinterpreting symptoms as asthma or COPD exacerbation, as this could lead to potentially fatal outcomes. Presentation: 6/1/2024

A Rare Case of Aconite Poisoning in a Tertiary Care Center in Nepal: Clinical Presentation and Management

Introduction: Aconite poisoning, caused by the toxin aconitine in the Aconitum genus (monkshood or wolfsbane), can be severe and requires supportive care as there is no specific antidote. Aconitine inhibits sodium channel inactivation, leading to dangerous cardiovascular and neurological symptoms.  Case Presentation: A 46-year-old male ingested half of a suspected aconite seed, leading to abdominal cramping, persistent vomiting, tingling sensations, and weakness. Upon admission, he exhibited hypotension, tachycardia, and bilateral mydriasis. ECG showed ventricular premature contractions. Treatment included intravenous amiodarone, magnesium sulfate, calcium gluconate, and gastric lavage with activated charcoal. He was admitted to the ICU for intensive monitoring and treatment, including ongoing amiodarone administration. After improvement, he was transferred to the general ward and later discharged.  Discussion: Aconite poisoning involves symptoms from aconitine's effect on sodium channels, including arrhythmias, hypotension, and neurological issues. Management focuses on supportive care, antiemetics, and monitoring. Advanced treatments like flecainide or amiodarone may restore normal heart rhythm, and severe cases might require a cardiac bypass or VA- ECMO.  Conclusion: This case describes a rare aconite poisoning with severe neurological, cardiovascular, and gastrointestinal symptoms after ingestion of a suspected aconite seed. The patient was treated with decontamination, intravenous amiodarone, and ICU care, leading to recovery. Despite its traditional use, aconite poisoning often results from its application without proper regulation, highlighting the need for rapid diagnosis and management.

The effect of intravenous calcium gluconate on the prevention of ovarian hyperstimulation syndrome. (A randomized clinical trial)

ObjectiveOral Cabergoline and intravenous Calcium have the potential to prevent Ovarian Hyperstimulation Syndrome (OHSS) in assisted reproductive technology by regulating the activity of the Vascular Endothelial Growth Factor (VEGF) receptor. The purpose of this study was to examine the effect of Cabergoline with intravenous Calcium versus oral Cabergoline alone on the overall rate of OHSS. MethodsThis study is a randomized clinical trial which was carried out in Milad Infertility Center affiliated with Mashhad University of Medical Sciences, Mashhad, Iran between April 2016 and January 2018. A total of 192 patients were randomly assigned into two groups. The control group received oral Cabergoline and the intervention group received Calcium gluconate in addition to Cabergoline. A total rate of OHSS, moderate and severe OHSS were measured in both groups. ResultsThe demographic characteristics of the participants and the types of drugs used showed homogeneity between the intervention and control groups (P > 0.05). Furthermore, there was no significant difference between the two groups in terms of the number of the follicle, oocytes obtained, metaphase II oocytes, the number of embryos, and the rate of fertilization. Regarding the incidence of OHSS, 26.2 % of participants in the control group experienced OHSS, while the occurrence rate was 15.7 % in the intervention group (P = 0.401). The incidence of severe OHSS in the control group and intervention group was 7.1 % and 3.6 %, respectively. ConclusionIntravenous injection of Calcium gluconate can be effective in preventing Ovarian Hyperstimulation Syndrome.

#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.