Intravenous Calcium Research Articles

Atypical case of hypermanganesemia with dystonia type 1: a treatable primary dystonia caused by inborn error of manganese metabolism

Dystonia is one of the most common movement disorders in the pediatric age group. Dystonia with hypermanganesemia have polycythemia with deranged iron profile, chronic liver disease and basal ganglia hyperintensity on T1 weighted MRI brain image as characteristic finding. We are reporting one case of dystonia, lower limb weakness, polycythemia, and characteristic basal ganglia hyperintensity with a normal iron profile without liver involvement which diagnosed as inherited manganese (Mn) transporter defect due to homozygous mutations of SLC30A10 gene. Most of the reported cases of this mutation have reported decreased iron profile in their blood report and liver involvement contrary to our case. Intravenous disodium calcium edetate chelation and oral iron therapy led to a decrease in whole blood Mn level as well as clinical improvement in the patient. This is a rare disorder and is one of the potentially treatable inherited metal storage disorders and fatal if left untreated.

Rationale and design of the NODE-303 study: evaluating the safety of symptom-prompted, self-administered etripamil for paroxysmal supraventricular tachycardia episodes in real-world settings

Paroxysmal supraventricular tachycardia (PSVT) is a common episodic arrhythmia characterized by unpredictable onset and burdensome symptoms including palpitations, dizziness, chest pain, distress, and shortness of breath. Treatment of acute episodes of PSVT in the clinical setting consists of intravenous adenosine, beta-blockers, and calcium channel blockers (CCBs). Etripamil is an intranasally self-administered L-type CCB in development for acute treatment of AV-nodal dependent PSVT in a non-medical supervised setting. This paper summarizes the rationale and study design of NODE-303 that will assess the efficacy and safety of etripamil. In the randomized, double-blinded, placebo-controlled, Phase 3 RAPID trial, etripamil was superior to placebo in the conversion of single PSVT episodes by 30 minutes post initial dose when administered in the non-healthcare setting; this study required a mandatory and observed test dosing prior to randomization. The primary objective of NODE-303 is to evaluate the safety of symptom-prompted, self-administered etripamil for multiple PSVT episodes in real-world settings, without the need for test dosing prior to first use during PSVT. Secondary endpoints include efficacy and disease burden. Upon perceiving a PSVT episode, the patient applies an electrocardiographic monitor, performs a vagal maneuver, and, if the vagal maneuver is unsuccessful, self-administers etripamil 70 mg, with an optional repeat dose if symptoms do not resolve within 10 minutes after the first dose. A patient may treat up to four PSVT episodes during the study. Adverse events are recorded as treatment-emergent if they occur within 24 hours after the administration of etripamil. Efficacy endpoints include time to conversion to sinus rhythm within 30 and 60 mins after etripamil administration, and the proportion of patients who convert at 3, 5, 10, 20, 30, and 60 min. Patient-reported outcomes are captured by the Brief Illness Perception Questionnaire, the Cardiac Anxiety Questionnaire, the Short Form Health Survey 36, the Treatment Satisfaction Questionnaire for Medication and a PSVT survey. Overall, these data will support the development of a potentially paradigm-changing long-term management strategy for recurrent PSVT.

Effect of early intravenous calcium replacement after total thyroidectomy

Aim: This study was to evaluate the need for postoperative calcium replacement in patients undergoing total thyroidectomy, to evaluate the effect of intravenous calcium therapy given in the early postoperative period regardless of serum calcium level and physical examination on the length of stay of the patients, parathormone levels, and the need for oral calcium after discharge. Materials and Methods: The files of 73 patients who underwent bilateral total thyroidectomy between January 2018 and July 2023 were retrospectively reviewed, and the demographic characteristics, anti-TG, anti-TPO, postoperative calcium, parathormone, thyroid gland weight of the patients were recorded. The effect of intravenous calcium replacement on calcium requirement, parathormone levels, and length of hospitalization was evaluated independently of calcium levels. Results: It has been observed that replacement is associated with long-term calcium requirement in patients who underwent bilateral total thyroidectomy and received intravenous calcium in the early period. The length of stay was found to be longer in patients who underwent calcium replacement. Conclusion: Various treatment methods are used to prevent hypocalcemia. One of these treatment methods is early intravenous calcium replacement. In clinical practice, treatments given to prevent the development of complications and to discharge patients early may sometimes lead to the occurrence of complications that are tried to be prevented. The purpose of calcium replacement is to prevent the development of hypocalcemia, to reduce the complication rate and to provide early discharge. It was evaluated that intravenous calcium replacement therapy, which was applied in the early period to prevent postoperative hypocalcemia, caused patients to need longer-term calcium replacement and prolonged hospitalization. It is important to avoid calcium replacement in the early period and to evaluate the physical examination findings along with the serum calcium level of the patients for replacement.

The Challenge of Preoperative Panel Reactive Antibody Positivity in Parathyroid Transplantation.

Identifying suitable recipient criteria and matching recipients with appropriate donors are required to increase survival for parathyroid transplant. This study was undertaken to evaluate transplant survival rates while comparing preoperative panel reactive antibody positivity. The study included 14 hypoparathyroidism patients who presented to our clinic for parathyroid transplant. Preoperative ABO compatibility and negative cross-match tests were prioritized for recipient-donor matching, and panel reactive antibody screening tests were performed. During the 24-month follow-up, we evaluated medication use and serum calcium, phosphorus, and parathormone levels of patients. Preoperative panel reactive antibody positivity was assessed in 3 groups. The HLA class I-positive group (mean fluorescence intensity range, 179-1770) showed decreased medication use and stability in serum calcium levels. The HLA class IIpositive (mean fluorescence intensity range, 85-3959) showed decreased medication use by 25% to 50% and returned to their former prescription doses after 12 months. An opposite pattern was observed in 2 patients with panel reactive antibody positivity for both HLA classes (mean fluorescence intensity range, 462-2289), with 1 patient requiring medication for continuing symptoms and the other patient occasionally taking additional magnesium supplementation, despite decreased medication doses after 12 months. Serum calcium levels remained normal, and parathormone and phosphorus levels were elevated. Improving patient symptoms and having no requirement for intravenous calcium replacement are priorities, and monitoring serum levels is the next important step. Varied panel reactive antibody positivities and survival rates indicate a requirement, and each HLA class could require a proper limitation for the mean fluorescence intensity. Preoperative mean fluorescence intensity cut-off value should be <900. Higher mean fluorescence intensity values in panel reactive antibody screenings could increase risk of short-term graft survival after parathyroid transplant. Further studies should include immunological risk assessments by individualizing the outcome with donor-specific antibodies.

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.

Intravenous calcium therapy in calcium channel blocker poisoning - A double-edged sword.

Intravenous calcium therapy in calcium channel blocker poisoning - A double-edged sword.

Evaluation of a novel dipotassium phosphate bolus for treatment of metabolic disorders in dairy cattle.

A dipotassium phosphate bolus (K Phos-Boost) has been developed to treat both hypophosphatemia and hypokalemia, as the clinical signs of both conditions are similar and occur in the early post-partum period. The objective of this research was to evaluate the efficacy and application of the bolus for prevention and treatment of metabolic diseases that are common in dairy production systems. Study 1 (Pharmacokinetic study): Healthy post-partum cows were either untreated or received two K Phos-Boost boluses at times 0, 24, and 48 h. Blood was taken at t = 0, 2-, 4-, 6-, 8-, 10-, 24-, and 52-h post-treatment for analysis of total serum minerals. There was an increase in serum phosphorous to normal levels within 2 h of treatment with the bolus, but control cows remained hypophosphatemic. Serum potassium was significantly elevated 2 h after bolus administration relative to control, while calcium, magnesium, sodium, and chloride levels were not affected by the K Phos-Boost bolus. Study 2 (Downer Cow Treatment): K Phos-Boost boluses were provided to cows that were unresponsive to intravenous calcium therapy and had been unable to stand for over 24 h ("downer cows"). Most cows (16 of 19) treated with two boluses were standing without assistance between 1 and 24 h after treatment and the serum phosphorous was increased to normal levels in five of five tested animals. Study 3 (Ketosis Treatment): cows with clinical ketosis were provided with propylene glycol and K Phos-Boost boluses (n = 29) or only propylene glycol (n = 23). Cows treated with the K Phos-Boost bolus showed a more rapid recovery by increased milk production (3.9 kg/day) and rumination rate (97 min/day). Study 4 (Health Promotion): cows in herds with >40% post-partum hypophosphatemia received K Phos-Boost boluses (n = 130) or no treatment (n = 146) following calving. There was a trend for treated 2nd-lactation animals to have higher milk production after 30 DIM (49.1 vs. 46.2 kg/day; P = 0.09). There were no significant differences between control and bolus treated animals in the incidence of subclinical ketosis, post-calving total health events, or culling rates. The K Phos-Boost bolus is a novel product and has the potential to treat and prevent several important metabolic diseases in dairy cattle. The studies described in this paper are early investigations and further research should be conducted to demonstrate the applications of a dipotassium phosphate bolus in dairy cows.

Abstract 15597: Unlocking Rate Control in Atrial Fibrillation: A Closer Look at the Intravenous Diltiazem and Metoprolol Duel - An Updated Systematic Review and Meta-Analysis

Background: Intravenous beta-blockers and calcium channel blockers remain first-line therapeutic agents for hemodynamically stable atrial fibrillation patients with a rapid ventricular rate (AF-RVR) in emergency medical settings. Material and Methods: We conducted a thorough review of various sources, including PubMed, Embase, Cochrane databases, and clinicaltrials.gov registry. Our search covered the period from the inception of these databases up to May 20, 2023. We only selected studies that compared the effectiveness and safety of diltiazem and metoprolol in adult patients with AF-RVR who were in emergency medical settings or hospitalized. We focused on whether the drugs successfully controlled heart rate and if there were any cases of hypotension or bradycardia following drug administration. Results: Among the 150 identified studies, 19 were suitable. All these studies demonstrated a low to moderate risk of bias. The meta-analysis, using the Mantel-Haenszel random-effects model, revealed a higher success rate in achieving the rate control target with diltiazem compared to metoprolol [19 studies, n = 1732, Odds Ratio (OR): 1.65; 95% Confidence Intervals (CI):1.18 to 2.32; I^2 = 58%, P = 0.001]. In terms of safety, no significant difference was observed in the risk of hypotension with either drug [15 studies, n = 1477, OR: 1.12; 95% CI: 0.76 to 1.64; I^2 = 25%, P = 0.18]. However, an incidence of bradycardia was noticed with diltiazem [7 studies, n = 1203, OR: 2.85; 95% CI: 1.25 to 6.46; I^2 = 21%, P = 0.27]. Conclusions: For patients with AF-RVR, intravenous diltiazem was more successful in achieving the desired rate control than metoprolol. Both drugs had similar rates of hypotension, but diltiazem had a slightly higher risk of bradycardia. These results indicate that diltiazem may be a better option for rate control in AF-RVR patients. However, high-quality randomized studies are needed to assess both medication's long-term safety and effectiveness in this group.

Intravenous Calcium to Decrease Blood Loss During Intrapartum Cesarean Delivery: A Randomized Controlled Trial.

To evaluate whether prophylactic administration of 1 g of intravenous calcium chloride after cord clamping reduces blood loss from uterine atony during intrapartum cesarean delivery. This single-center, block-randomized, placebo-controlled, double-blind superiority trial compared the effects of 1 g intravenous calcium chloride with those of saline placebo control on blood loss at cesarean delivery. Parturients at 34 or more weeks of gestation requiring intrapartum cesarean delivery after oxytocin exposure in labor were enrolled. Calcium or saline placebo was infused over 10 minutes beginning 1minute after umbilical cord clamping in addition to standard care with oxytocin. The primary outcome was quantitative blood loss, analyzed by inverse Gaussian regression. Planned subgroup analysis excluded nonatonic bleeding, such as hysterotomy extension, arterial bleeding, and occult placenta accreta. We planned to enroll 120 patients to show a 200-mL reduction in quantitative blood loss in planned subgroup analysis, assuming up to 40% incidence of nonatonic bleeding (80% power, α<0.05). From April 2022 through March 2023, 828 laboring parturients provided consent and 120 participants were enrolled. Median blood loss was 840 mL in patients allocated to calcium chloride (n=60) and 1,051 mL in patients allocated to placebo (n=60), which was not statistically different (mean reduction 211 mL, 95% CI -33 to 410). In the planned subgroup analysis (n=39 calcium and n=40 placebo), excluding cases of surgeon-documented nonatonic bleeding, calcium reduced quantitative blood loss by 356 mL (95% CI 159-515). Rates of reported side effects were similar between the two groups (38% calcium vs 42% placebo). Prophylactic intravenous calcium chloride administered during intrapartum cesarean delivery after umbilical cord clamping did not significantly reduce blood loss in the primary analysis. However, in the planned subgroup analysis, calcium infusion significantly reduced blood loss by approximately 350 mL. These data suggest that this inexpensive and shelf-stable medication warrants future study as a novel treatment strategy to decrease postpartum hemorrhage, the leading global cause of maternal morbidity and mortality. ClinicalTrials.gov, NCT05027048.

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.&#x0D; Aim To determine the prophylactic efficacy of 400 vs. 200 mg/kg/day calcium gluconate in preventing neonatal hypocalcemia.&#x0D; 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.&#x0D; 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).&#x0D; Conclusion Prophylactic intravenous calcium gluconate at 400 mg/kg/day was not more effective in preventing neonatal hypocalcemia than 200 mg/kg/day.

Outcomes of subtotal parathyroidectomy for renal hyperparathyroidism

BackgroundRenal hyperparathyroidism due to end-stage kidney disease is associated with considerable morbidity, and when refractory is treated with parathyroidectomy. Recurrent renal hyperparathyroidism is a major surgical complication, yet initial target parathyroid remnant size and outcomes, including rates of recurrence are not well elucidated. MethodsThis is a single-institution retrospective cohort study of patients who underwent initial subtotal parathyroidectomy for renal hyperparathyroidism on dialysis, from 1990–2022. The subtotal parathyroidectomy was defined as resection of 3 parathyroid glands ± partial resection of the fourth gland leaving a remnant of ∼75–100 mg, and postresection intraoperative parathyroid hormone goal was 150–250 pg/mL. Clinical data were examined for outcomes. ResultsAmong 204 patients who met inclusion criteria, 139 (68%) had follow-up data; 58% (80/139) were women and median age was 45 years. Surgical complications included 2 hematomas (1.4%), 1 recurrent laryngeal nerve injury (<1%), and no patient required readmission for intravenous calcium. Using a target remnant size of 75–100 mg, recurrent renal hyperparathyroidism was uncommon (14/139, 10%) and arose at a median interval of 58.6 months (range, 8–180). In cases of recurrence, the postresection intraoperative parathyroid hormone level was less likely to drop <250 pg/mL (40%, 4/10 vs nonrecurrence 65%, 80/123; P = .11) with a slightly lower median decrease (70% vs 81% in nonrecurrence, P = .8); however, neither were significant. Recurrence did not occur in the 19 patients who later received kidney transplantation (P = .2). ConclusionIn subtotal parathyroidectomy for renal hyperparathyroidism, use of a target 75–100 mg remnant size results in low complication rates. Durable cure appears to be more likely with renal transplantation.

SAT217 Chronic Asymptomatic Hypoparathyroidism Due To Two Separate Single Nucleotide Heterozygous Mutations In The CaSR Gene

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. S. Storm: None. P. Russell: None. V. Verma: None. R. Kant: None. Introduction: The most common cause for acquired hypoparathyroidism is either post-surgical or autoimmune destruction of the parathyroid glands. The clinical presentation can range from an asymptomatic state to severe life-threatening symptoms that require intensive therapeutic management with intravenous and/or oral calcium, calcitriol and in some cases, recombinant parathyroid hormone therapy. Hypoparathyroidism secondary to CASR (calcium sensing gene receptor) gene mutation is an uncommon etiology that can also have a varied clinical presentation as above. Clinical Case: A 60-year-old Caucasian male with no significant past medical history was found to have chronic hypocalcemia. He denied experiencing symptoms such as numbness, tingling or cramping sensation around face, lips, or upper extremities. He denied a history of movement disorder or dental problems. He denied a history of neck surgeries or neck radiation exposure. He denied a family history of calcium disorders. He was on calcium carbonate/Vitamin D3 600 mg/400 I.U once daily. The first documented low corrected serum calcium was 6.9 mg/dl (8.6-10.0 mg/dl) in November of 2017. Since then, there have been multiple low corrected serum calcium levels ranging between 7 to 7.6 mg/dl. Patient underwent endocrinology work-up after withholding the above calcium/Vitamin D3 supplementation and it revealed a low corrected serum calcium of 7.6 mg/dl with an inappropriately normal serum PTH level of 37 pg/ml (15-65 pg/ml), normal vitamin D level of 45.1 ng/ml (&amp;gt; 30.0 ng/ml), normal serum phosphorus 3.8 mg/dl (2.5-4.5 mg/dl), and normal serum magnesium 1.8 mg/dl (1.6-2.6 mg/dl). The 24-hour urine calcium was 93 mg/24 hour with a corresponding 24-hour urine creatinine of 1836 mg (1040-2350 mg/24hour) and urine volume of 1625 ml. CASR gene analysis revealed two separate single nucleotide heterozygous mutations. The first mutation was at Exon 4/7, nucleotide position was c.614G&amp;gt;A and Amino Acid position was p.Arg205His. The second mutation was at Exon 7/7, nucleotide position was c.2546T&amp;gt;C and Amino Acid Position is p.lle849Thr. Due to lack of specific symptoms, patient was not initiated on specific therapies such as calcitriol or Natpara (recombinant PTH) and was advised to continue taking the daily calcium/vitamin D3 supplementation. He is being currently monitored every 4 to 6 months to assess for any clinical symptoms along with pertinent laboratory work-up. Conclusion: Hypoparathyroidism due to CASR gene mutation has a varied clinical presentation. One-third of cases do not develop any clinical symptoms, such as our patient and hence do not warrant any specific treatment other than periodic clinical and biochemical assessment. Presentation: Saturday, June 17, 2023

SAT239 Deceased Donor Parathyroid Allotransplant For Sever Refractory Iatrogenic Hypoparathyroidism

Abstract Disclosure: K.M. Devon: None. A. Zahedi: None. A. Madani: None. J.D. Pasternak: None. B. Saravana-Bawan: None. A. Humar: None. T. Kathryn: None. While Halstead experimented with dog parathyroid transplantation, the first reported human parathyroid allotransplant appeared in the Annals of Surgery in 1911. Efforts of varying success in restoring calcium homeostasis in patients with refractory hypoparathyroidism after thyroidectomy have included parathyroid transplantation(tx), mainly in immunosuppressed kidney transplant recipients, using cryopreserved, cultured, or hypercellular tissues. Recently, cases of living-donor parathyroid allotransplants have been reported. We present a 46 year-old woman who developed hypoparathyroidism following total thyroidectomy 9 years prior. Treatment included two years of continuous teriparatide via CAD pump. Complications of portacath sepsis and pulmonary emboli, required intensive care. At the time of transplantation, our patient was taking elemental calcium 16 grams daily, magnesium 12 grams daily, calcitriol 8 ug daily, hydroochlorothiazide 25 mg twice daily, and nonetheless requiring biweekly intravenous calcium for symptoms and Calcium levels of 1.6 mmol/l (2.2-2.6 mmol/L). PTH ranged between 0.6- 1.2 pmol/l with poor quality of life. A medically suitable neurologically deceased donor was identified through the provincial organ donation organization. Her cumulative cPRA was 98% (Class I-95%/II-81%). Virtual crossmatch only positive for DQ2 specificity with weak positive B-cell flow crossmatch. Four healthy parathyroids were retrieved. The tissue was minced and placed into pockets in the recipient’s right brachioradialis muscle, under local anaesthesia with sedation. Ischemic time was 2.5 hours. She was induced with basiliximab and received tacrolimus, mycophenolate, and prednisone as immunotherapy. Evidence of biochemical parathyroid function was present post-tx day 9, and she was weaned off all calcium homeostatic medications by day 35, remaining asymptomatic at 7 months at the time of writing, with no calcium infusions. Self-reported quality of life is significantly improved. PTH 0.8-2.8 pmol/L and Calcium 2.06-2.37 mmol/l. To our knowledge this is the first successful fresh normal tissue deceased donor parathyroid transplant in a non-transplant recipient in North America. One study suggests that despite immunosuppression risks, 14 percent of patients would entertain parathyroid allotransplantation. We are currently recruiting additional patients with the aim of demonstrating that deceased donor parathyroid allotransplant using fresh tissue and immunosuppression is a novel viable and curative approach to treat permanent severe hypoparathyroidism. Presentation: Saturday, June 17, 2023

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

SAT229 Symptomatic Hypocalcemia In The Setting Of Crohn’s Disease With Severe Hypomagnesemia

Abstract Disclosure: K. Cuan: None. T. Reisman: None. Introduction: People with Crohn’s Disease (CD) are at risk for various nutritional deficiencies due to decreased oral intake, malabsorption, and increased intestinal losses. CD often causes a negative calcium balance, which does not usually cause hypocalcemia because the bones serve as a reservoir for calcium. However, symptomatic hypocalcemia may occur if a concurrent severe hypomagnesemic state is present. The factors resulting in hypocalcemia in patients with magnesium deficiency are impaired PTH secretion, PTH resistance, and vitamin D deficiency. Clinical Case: A 33-year-old man with CD and rheumatoid arthritis presented following a seizure with additional symptoms of hand cramping and facial twitching. He had previously undergone three small bowel resections and had a history of hypocalcemia due to malabsorption. Although this patient had previously been admitted due to a hypocalcemic seizure, he did not start oral calcium supplements at that time. No issues with magnesium were identified previously. On this encounter, he was found to have a corrected calcium (cCa) of 5.3 mg/dL, undetectably low magnesium at &amp;lt;0.7 mg/dL, normal phosphorus, 25-hydroxyvitamin D at 3.5 ng/mL, and an elevated intact PTH (iPTH) at 169 pg/mL. Aggressive intravenous calcium and magnesium repletion improved cCa to 7.4 mg/dL and magnesium to 2 mg/dL with no further seizure activity. He was discharged on calcium carbonate, calcitriol, and ergocalciferol. A month later, he presented to our endocrinology clinic asymptomatic but with a cCa of 6 mg/dL and magnesium at &amp;lt;0.7 mg/dL. Further biochemical workup revealed normal phosphorus, 25-hydroxyvitamin D at 7.9 ng/mL, and an inappropriately normal iPTH at 49 pg/mL. He was readmitted to the hospital where intravenous repletion improved cCa to 8.1 mg/dL and magnesium to 1.9 mg/dL. His recurrent hypomagnesemia was attributed to malabsorption. An increased dose of calcitriol and oral magnesium were added to his discharge medication regimen, in addition to his ergocalciferol and calcium carbonate. Three days later, he had a cCa level of 7.1 mg/dL as an outpatient. Conclusion: Patients with CD often have nutrient deficiencies, especially if they have had surgical resection within the intestinal tract. Our patient initially developed hypocalcemia from malabsorption, which was then exacerbated by the severely hypomagnesemic state. During his initial hospital encounter, the elevated iPTH level indicated PTH resistance. On his second encounter, the normal iPTH level suggested hypoparathyroidism. Given the relationship between magnesium and calcium homeostasis, addressing the hypomagnesemia eventually aided in achieving stabilization of serum calcium levels. Thus, in patients who are at risk for malabsorption and have recurrent symptomatic hypocalcemia, it is prudent to check magnesium levels as it can affect long term management of hypocalcemia. Presentation: Saturday, June 17, 2023

Malignant Infantile Osteopetrosis: A Rare Cause of Refractory Hypocalcemia

Background: Infantile malignant osteopetrosis (IMO) is a rare autosomal recessive disease characterized by a higher bone density in bone marrow caused by the dysfunction of bone resorption. Clinical Description: A 2-month-old baby boy presented with features of lower respiratory tract infection, along with a swollen right upper arm due to fracture of humerus, along with signs of bicytopenia and hepatosplenomegaly. He had a history of hypocalcemic seizures at 8th day of life. Management and Outcome: Current hospitalization revealed refractory hypocalcemia and hypophosphatemia with normal to increased Vitamin D and parathormone levels and increased density of bone. Hypocalcemia was particularly refractory in nature needing multiple intravenous calcium corrections. Whole exome sequencing detected compound heterozygous variants in the T-cell immune regulator 1 pathogenic gene of IMO. Simultaneously, a heterozygous nonsense variation in exon 4 of the CHRNA4 gene was detected causing nocturnal frontal lobe epilepsy. As the infant had evidence of bone marrow failure, he was considered and referred for hematopoietic stem cell transplantation. Conclusion: Neonatal and early infantile hypocalcemia are commonly seen by pediatricians, but an etiology of IMO is rarely considered. The presence of fracture of long bones with cytopenias and hepatosplenomegaly in a young infant with recurrent hypocalcemia, without Vitamin D deficiency, should raise suspicion of this disorder and genetic analysis should be carried out for the same.

Reduction of Calcium Scores Using Intravenous Chelation: A Retrospective Pilot Study.

This pilot study presents a retrospective analysis of 10 asymptomatic patients with a positive calcium score who received a series of intravenous calcium ethylenediaminetetraacetic acid (EDTA) chelations. Current standards for cardiovascular risk stratification include assessments of cholesterol, blood pressure, blood sugar, lifestyle, obesity, and family history. Despite addressing traditional risk factors, myocardial infarctions and cerebrovascular accidents remain the leading causes of death and disability worldwide. Asymptomatic decay of the vascular system is a prelude to catastrophic events, and calcium scores are emerging as a significant adjunct for risk assessment. Positive calcium scores correlate with an increased risk of cardiovascular events. However, there are no therapies known to reliably reverse calcium scores. Previous studies have demonstrated that intravenous chelation therapy reduces cardiovascular morbidity and mortality in patients with a prior history of myocardial infarction; however, its mechanism of action is unknown. One theory is that chelation therapy would reverse calcium buildup in coronary arteries, which is known to have a positive correlation with the risk of having a cardiovascular event. The 10 patients had no prior history of coronary artery disease. Infusions were administered in an outpatient setting. Patients were encouraged to receive a treatment every month. No other supplements or prescriptions were required as part of the treatment. An average of 26.9 chelations were administered over an average of 37.9 months. Calcium scores decreased by an average of 27.38%, and all 10 patients experienced a reduction in scores. This study demonstrates that chelation has the potential to reduce calcium scores. Since calcium scores correlate with cardiovascular risk, reducing the calcium score may reduce the risk of an event. If these results are supported by larger, placebo-controlled studies, chelation therapy may become an option that could be added to statins and other FDA-approved therapies for primary prevention in patients with a positive calcium score.

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.

Comparative Efficacy of Sodium Zirconium Cyclosilicate and Sodium Polystyrene Sulfonate for Acute Hyperkalemia: A Retrospective Chart Review.

Background: Sodium polystyrene sulfonate (SPS) is a nonselective sodium-potassium exchange resin commonly used along with intravenous (IV) insulin, albuterol, furosemide, and/or calcium for the treatment of acute hyperkalemia. Sodium zirconium cyclosilicate (SZC) is a newer non-absorbed exchange resin that preferentially increases fecal potassium excretion from the gastrointestinal tract. Limited data exists on the efficacy of SZC for the treatment of acute hyperkalemia. Objectives: To assess the achievement of normokalemia (serum potassium level [K+] 3.5-5.2 mmol/L) within 24 hours after administration of SZC or SPS in combination with insulin regular IV push. Methods: A multicenter, retrospective chart review (2020-2021) using electronic medical records at an academic health system. The study population included adult patients receiving one or more doses of SZC or SPS in combination with IV insulin for acute hyperkalemia (K+ >5.2 mmol/L). Patients receiving dialysis were excluded. Serum chemistries were assessed at baseline and an additional 2 values within 24 hours to determine normokalemia and hypokalemia at each follow-up. Results: Of 141 patients included, 51 received SZC and 90 received SPS. Normokalemia at the first follow-up was achieved in 51.0% of patients receiving SZC and 46.7% of patients receiving SPS (P = .622) and was sustained in 35.3%versus 44.4% (P = .289) of patients within 24 hours. Mean serum potassium differences from baseline to first follow-up were similar between SZC and SPS groups (0.9 mmol/L vs 1.0 mmol/L). Hypokalemia within 24 hours of administration occurred in 4 patients-1 in SZC, 3 in SPS. Conclusion: Both SZC and SPS yielded similar rates of normokalemia achievement with IV insulin for the treatment of acute hyperkalemia. Further prospective studies are needed to confirm these findings.

Severe hypocalcemia after denosumab treatment leading to refractory ventricular tachycardia and veno-arterial extracorporeal membrane oxygenation support: a case report

BackgroundSevere hypocalcemia may lead to life-threatening arrhythmias. Denosumab is an effective treatment for osteoporosis that allows long intervals between doses. However, there is a risk of hypocalcemia in some patients. Due to the long half-life of denosumab, emergency physicians caring for patients presenting with symptoms of hypocalcemia may not be aware of the medication, and adverse effects may last longer.Case presentationA 55-year-old woman with a history of systemic lupus erythematosus (SLE) and anxiety disorder called for an ambulance for symptoms of hyperventilation and muscle cramps. After evaluation at the local hospital, she developed pulseless ventricular tachycardia and was resuscitated by defibrillation by the hospital staff. After conversion to sinus rhythm, she was transported to a tertiary center. Upon arrival, pulseless ventricular tachycardia occurred again, and veno-arterial extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) were implemented. Laboratory results showed severe hypocalcemia (corrected calcium level of 5.3 mg/dL) whereupon intravenous calcium supplementation was started. She had received the first dose of denosumab (60 mg) by subcutaneous injection 24 days prior to hospitalization. She was eventually weaned from ECMO and IABP support.ConclusionCardiac arrest due to hypocalcemia is relatively rare but can be fatal. In the present case, hyperventilation may have acutely exacerbated pre-existing hypocalcemia, leading to ventricular tachycardia. The patient had a slightly decreased serum calcium level prior to denosumab. Close monitoring may be preferable after the primary dose of denosumab in selected patients. Emergency physicians caring for patients who may be suffering from symptoms/signs of hypocalcemia must be mindful of medications that have long half-lives and affect electrolyte balance when treating fatal arrhythmia due to hypocalcemia.