Life-threatening Hypocalcemia Research Articles

Late diagnosis of life-threatening hypocalcemia in a patient with hypoparathyroidism after hemithyroidectomy: A case report

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Overlooked and Unanticipated: Life-Threatening Hypocalcemia due to Denosumab in a Patient with Prostate Cancer

Overlooked and Unanticipated: Life-Threatening Hypocalcemia due to Denosumab in a Patient with Prostate Cancer

The Incidence of Thyroid Gland Invasion in Patients with Carcinoma of the Larynx who Underwent Total Laryngectomy

Introduction: Total thyroidectomy or at least hemithyroidectomy is routinely performed alongside total laryngectomy in patients with advanced carcinoma of the larynx. Life-threatening hypocalcaemia and hypothyroidism are common sequelae especially with adjuvant radiation. The study aims to determine the incidence of microscopic thyroid gland invasion and challenge the idea of routine thyroidectomy in advanced carcinoma of the larynx. Materials and Methods: This study was a retrospective observational study. It was done in two tertiary centres in Malaysia between 2003 and 2013 for a total duration of 11 years. A total of 72 patients were included in this study. Data from medical records, operative notes, and histopathological reports were collected and analysed. Results: Three patients (4.2%) had the presence of microscopic thyroid gland invasion. There were no significant associations between microscopic thyroid gland invasion and tumour subsites, histological types of a tumour nor T staging (p>0.05) Conclusion: The incidence of microscopic thyroid gland invasion in advance carcinoma of the larynx is low, disavowing routine thyroidectomy. Limitations: Some factors such as cartilage invasion on CT imaging and central lymph node treatment were not considered due to limitations in case documentation.

The use of cinacalcet after pediatric renal transplantation: an international CERTAIN Registry analysis.

Secondary hyperparathyroidism (SHPT) may persist after renal transplantation (RTx), inducing hypophosphatemia and hypercalcemia that precludes the use of vitamin D analogs. The calcimimetic cinacalcet improved plasma calcium and parathyroid hormone (PTH) levels in randomized controlled trials in adults after RTx, but pediatric data are scarce. In this retrospective study, we analyzed 20 pediatric patients from the Cooperative European Paediatric Renal TransplAnt Initiative (CERTAIN) Registry who received cinacalcet after RTx. The results are presented as median and interquartile range (25th-75th percentile). At 13.7 (11.0-16.5) years of age, 20 pediatric patients received a renal allograft. Cinacalcet was introduced at 0.4 (0.3-2.7) years post-transplant at an estimated glomerular filtration rate (eGFR) of 50 (34-66) mL/min/1.73m2, plasma calcium of 2.58 (2.39-2.71) mmol/L, age-standardized (z score) phosphate of - 1.7 (- 2.7-- 0.4), and PTH of 136 (95-236) ng/L. The starting dose of cinacalcet was 0.5 (0.3-0.8) mg/kg per day, with a maximum dose of 1.1 (0.5-1.3) mg/kg per day. With a follow-up of 3.0 (1.5-3.6) years on cinacalcet therapy, eGFR remained stable; PTH levels decreased to 66 (56-124) ng/L at the last follow-up (p = 0.015). One patient displayed hypocalcemia (1.8mmol/L). Cinacalcet was withdrawn in three patients (hypocalcemia, parathyroidectomy, incompliance). Nephrocalcinosis of the graft was not reported. This pilot study suggests that cinacalcet as off-label therapy for SHPT after pediatric RTx is efficacious in controlling post-transplant SHPT with acceptable tolerability. Continuing cinacalcet even with normal PTH can lead to dangerous life-threatening hypocalcemia. Therefore, at each subsequent visit, the need to continue cinacalcet must be assessed.

Life-Threatening Hypocalcemia in A Patient with highly suspected osteomalacia: A Case Report

ABSTRACT Objective: Osteomalacia is a metabolic bone disease characterized by impaired mineralization with increased non-mineralized osteoid tissue, increased frailty, and reduced bone mineral density. A common cause of osteomalacia in adults and the elderly is severe deficiency of vitamin D, which leads to chronic hypocalcemia, hypophosphatemia, and secondary hyperparathyroidism. The objective of this case report is to describe an unusual clinical presentation of osteomalacia, consisting of life-threatening acute hypocalcemia. Methods: Clinical, laboratory, and imaging data are presented. Results: We report the case of a 65-year-old man that showed symptoms and signs of severe and prolonged hypocalcemia due to unrecognized vitamin D deficiency. He presented at the emergency room reporting abdominal pain and vomiting since the evening before. Blood tests showed increased levels of rhabdomyolysis markers, severe hypocalcemia, hypophosphatemia, hypomagnesemia, normal renal function, elevated levels of alkal...

Severe Hypocalcemia After the Administration of Zoledronic Acid for Osteoporotic Fracture

Zoledronic acid is a potent intravenous bisphosphonate used in the treatment of osteoporosis and malignancy-induced hypercalcemia or bone metastasis. Although zoledronic acid generally seems to be safe and well-tolerated, rare but life-threatening nephrotoxicity or hypocalcemia may occur. The majority of cases of hypocalcemia with zoledronic acid have been seen in patients with underlying malignancy and are asymptomatic or mild. Vitamin D deficiency, renal failure, hypoparathyroidism, and hypomagnesemia have been reported as risk factors for hypocalcemia. Here, the author reports a case of severe symptomatic hypocalcemia following the administration of zoledronic acid for the treatment of osteoporotic fracture. This patient also had underlying but unrecognized vitamin D deficiency and chronic kidney disease. Following the administration of calcium and vitamin D, her symptoms improved and calcium levels returned to normal within several days. To avoid serious hypocalcemia with zoledronic acid, calcium and vitamin D status and renal function should be assessed and corrected if appropriate. J Med Cases. 2016;7(10):441-444 doi: http://dx.doi.org/10.14740/jmc2646w

Is denosmab really effective and safe in the care of CKD-MBD?

The authors of Freedom study enrolling primary osteoporosis patients argued that the anti-fracture effect of denosmab is not dependent on baseline estimated glomerular filtration rate(eGFR)by showing the non-significant interaction term between treatment and CKD stage. However, given disproportionate numbers of patients in each subgroup(4069, 2817, and only 73 patients, in CKD stage 2, 3, and, 4, respectively), this study seems to lack the statistical power to reach a definite conclusion on the effect modification by CKD stage. Truly, the serum concentration of infused denosmab in patients with CKD stage 4 is equivalent to that in patients without CKD, the risk of developing life-threatening or prolonged hypocalcemia is huge even under active vitamin D therapy in this population. In hemodialysis patients, this drug is relatively safer because each dialysis session delivers calcium into the circulation 3 times a week. However, even with concomitant administration of massive active vitamin D, the increase of intact PTH levels greater than 1000 pg/mL by this agent is not rare. In other words, this drug worsens secondary hyperparathyroidism. Moreover, reportedly, calcium and active vitamin D administered to avoid hypocalcemia can lead to ectopic calcification especially under the low bone turnover induced by this agent. In fact, transient hypercalcemia often follows hypocalcemia by the inevitable calcium supplementation.

Life-Threatening Hypocalcemia with Denosumab; Anaphylaxis in Two Children Receiving Etanercept; Fondaparinux Hepatotoxicity in a 6-Year-Old Child; Bullous Pemphigoid Induced by Dipeptidyl Peptidase-4 Inhibitors; Severe Neuroleptic Malignant Syndrome with Deep Coma Associated with Aripiprazole; Quetiapine-Induced Tardive Oculogyric Crisis

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the US Food and Drug Administration's (FDA's) MedWatch program (800-FDA-1088). If you have reported an interesting, preventable ADR to MedWatch, please consider sharing the account with our readers.

AB1015 Vitamin D level pre-intravenous bisphosphonate therapy

BackgroundIntravenous-bisphosphonates (IVB) are effective and very widely used in treatment of osteoporosis. Prior inadequate serum 25 hydroxyvitamin-D (25OHD), before administering IVB could lead to rapid life-threatening hypocalcaemia1,2. Also, it is...

Life-threatening hypocalcemia associated with denosumab in a patient with moderate renal insufficiency

Denosumab, a human monoclonal antibody to the receptor activator of nuclear factor-κB ligand, is a novel therapy to osteoporotic fracture and skeletal-related events in patients with bone metastases. Hypocalcemia is its known adverse effect, although it is generally mild and transient and usually occurs in patients with severe chronic kidney disease or end-stage renal disease. We reported a case 61-year-old woman who received a single dose of denosumab and developed severe symptomatic hypocalcemia associated with prolong QTc interval requiring hospitalization for intravenous calcium.

A Prospective Evaluation of Quick Intraoperative Parathyroid Hormone Assay at the Time of Skin Closure in Predicting Clinically Relevant Hypocalcemia after Thyroidectomy

BackgroundPost-thyroidectomy hypocalcemia is a major contributing factor in delayed hospital discharge and dissuading surgeons from ambulatory thyroidectomy. We prospectively evaluated the accuracy and reliability of quick parathyroid hormone level measurement at skin closure (PTH-SC) in predicting clinically relevant hypocalcemia (i.e., patients requiring calcium ± calcitriol supplements on hospital discharge).MethodsOf the 117 patients who underwent a total or completion total thyroidectomy and PTH-SC, 17 (14.5 %) had hypocalcemic symptoms or adjusted calcium <1.90 mmol/L requiring calcium and/or calcitriol supplements on discharge. Serum calcium was checked regularly in the perioperative period until stabilization and an additional quick PTH was checked on the following morning (PTH-D1). Univariate and multivariate analyses were performed to evaluate potential preoperative clinicopathologic factors and postoperative day 0 biochemical indicators. Youden’s index and the area under the ROC curve (AUC) were used to determine the best cutoff value and predictability of significant variables or criteria, respectively.ResultsIn the multivariate analysis, low preoperative adjusted calcium (p = 0.041) and low PTH-SC (p = 0.001) were the two independent variables associated with hypocalcemia. PTH-SC (≤1 or >1 pmol/L) had a higher specificity (95.0 %) and AUC (0.887) than serial calcium monitoring or PTH-D1 alone. Although 3/98 of patients with PTH-SC >1 pmol/L required calcium supplements on discharge, they required only the minimum amount to maintain normocalcemia.ConclusionPTH-SC is an accurate and reliable means of predicting clinically relevant hypocalcemia. It would be reasonable to discharge those with PTH-SC >1 pmol/L on the same operative day as the risk of life-threatening hypocalcemia would seem unlikely.

Life-Threatening Hypocalcemia following Subtotal Parathyroidectomy in a Patient with Renal Failure and Previous Roux-en-Y Gastric Bypass Surgery

Background. Roux-en-Y gastric bypass (RYGB) can result in calcium and vitamin D deficiency. Parathyroid surgery carries the risk of immediate and long-term hypocalcemia. Methods and Results. We describe a 54-year-old woman with history of end-stage renal disease and gastric bypass surgery who developed calciphylaxis requiring a 3.5-gland parathyroidectomy. Seven weeks later, she presented with weakness, perioral numbness, leg cramps, a positive Chvostek's sign, hypotension, prolonged QT-interval, and serum calcium of 5.4 mg/dL. Oral and intravenous calcium, calcitriol, and high calcium bath hemodialysis were given. She required 18 days of intravenous calcium and an outpatient maintenance regimen of calcitriol 6 mcg/day, calcium carbonate 8 grams/day, calcium citrate 1.2 grams/day, and ergocalciferol 50,000 IU/week. Conclusion. The patient's life-threatening prolonged hypocalcemia and large requirements of calcium and calcitriol were due to a combination of malabsorption, hypoparathyroidism, and renal failure. Special considerations should be given to bariatric surgery patients undergoing neck exploration.

Severe Symptomatic Hypocalcemia Following Total Thyroidectomy and Roux‐en‐Y Gastric Bypass

Patients who undergo Roux-en-Y gastric bypass (RYGB) procedures are at moderate risk for calcium and vitamin D deficiency. Those who subsequently undergo thyroid or parathyroid surgery are at high risk for developing severe symptomatic hypocalcemia if not monitored and prophylactically treated adequately. We present a morbidly obese patient who underwent Roux-en-Y gastric bypass six months prior to the discovery of metastatic papillary thyroid carcinoma. He subsequently underwent total thyroidectomy with central and bilateral neck dissection. Following surgery, he developed severe symptomatic hypocalcemia that reached a nadir of 6.0 mg/dL. He required aggressive oral and intravenous repletion therapy with calcium, vitamin D, and magnesium for ten days before hospital discharge. Providers should institute careful preoperative screening, patient counseling, and prophylactic calcium and vitamin D therapy for all RYGB patients who subsequently require thyroid surgery to prevent the development of severe and lifethreatening hypocalcemia. To date, only four reports have focused on the dangers of thyroid and parathyroid surgery in post gastric bypass surgery. We report this case to add to the growing body of literature for this patient population. CASE REPORT 40-year-old white male referred for evaluation of 5-cm neck mass, later determined to be metastatic papillary thyroid carcinoma 6 months prior, he had undergone RYGB for treatment of morbid obesity Preoperative calcium and TSH levels were within normal limits & preoperative medications included calcium citrate plus vitamin D He underwent total thyroidectomy with bilateral and central compartment lymph node excision, with autotransplantation of one parathyroid gland due to devascularization Following surgery, he was started on CaCO3 liquid suspension, elemental calcium, and cholecalciferol Over the first 24h his calcium dropped from 8.8 to 6.9 mg/dl and he remained asymptomatic. However, the following day he developed perioral numbness and a positive Chvostek’s sign, with calcium ranging from 6.7 to 7.3 mg/dl PICC access was obtained and he was treated symptomatically On POD 4, cholecalciferol was discontinued and ergocalciferol was started. CaCO3 was replaced with calcium citrate, HCTZ was initiated to decrease urinary calcium loss, and calcitriol was also started On POD 5-10, PTH increased from undetectable to 111 pg/mL, and calcium gradually improved from 6.6 to 8.3 mg/dL On POD ten, no signs or symptoms of hypocalcemia persisted, so the PICC line was removed and calcium citrate and ergocalciferol were continued PO Signs & symptoms of hypocalcemia were covered with the patient, and instructions were provided to return to the ED if symptoms returned At his three-week follow up appointment, calcium level was 8.2 mg/dL and he was experiencing no symptoms of hypocalcemia His current regimen includes ergocalciferol, calcium citrate, HCTZ, & calcitriol CONCLUSIONS  Patients undergoing thyroid or parathyroid surgery should be screened for a history of bariatric surgery. If positive, these patients should be counseled on the risk of developing severe hypocalcemia and pre-surgical prophylactic treatment with calcium and vitamin D should be instituted.  In the five reviewed reports of post-thyroidectomy hypocalcemia, all nine patients required intravenous calcium infusion to stabilize calcium levels. It follows, then, that precautionary PICC line placement should be acquired at the time of surgery for such patients.  Maximal replacement with oral calcium citrate, ergocalciferol, and calcitriol should be administered. We reserve intravenous calcium for symptomatic patients, in which case calcium gluconate should be considered.  Nursing staff should perform evaluations for symptomatic hypocalcemia q2h, including testing for Chvostek’s and Trousseau’s signs, as well as questioning about perioral and limb paresthesias.  Although not studied in this population, intramuscular teriparatide (recombinant PTH) injection may prove to be a useful drug in shortening hospital stay, and should be studied in the future.

Outpatient thyroidectomy: Experience in over 200 patients

Thyroidectomy has historically been performed on an inpatient basis out of fear of hemorrhage and transient but life-threatening hypocalcemia. An earlier favorable experience with outpatient surgery for a limited number of patients prompted our objective of an expanded evaluation of this practice. Retrospective analysis of a prospectively populated database. A consecutive single-surgeon series of patients undergoing thyroidectomy in an academic otolaryngology department between February 2003 and November 2007, including 91 patients assessed in a previous report. Clinical variables including age, gender, type of surgery, indications, and complications were obtained and analyzed. Principal outcome measures were length of hospital stay, incidence of complications, and rate of readmission. Four hundred eighteen patients underwent thyroid surgery during the study period. Two hundred eight were accomplished on an outpatient basis, 128 patients were observed under a 23-hour status, and 82 were admitted for a mean of 2.9 days (the latter two cohorts were grouped together and designated as inpatients). There were four complications in the outpatient group (1.9%) and 28 (13.3%) in the inpatient group (P < .001). Four individuals in the outpatient group (1.9%) required readmission compared with 5.7% (12/210) of those in the inpatient group, most commonly for transient hypocalcemia. The initial favorable experience with outpatient thyroid surgery has been validated in this expanded patient population of more than 200 patients. In rare instances, readmission may be required secondary to transient hypocalcemia. Modern surgical techniques, avoidance of drains, and prophylactic calcium supplementation have combined to make outpatient thyroidectomy safe in carefully selected patients.

Expositionen mit Ätzstoffen

Caustic injuries of the eye usually occur accidentally and can result in minor eye irritations to total loss of vision. All chemical exposures to the eye require immediate decontamination by copious irrigation with an aqueous solution for at least 15-30 minutes up to two hours in single cases of massive exposure. Tap water is readily available, safe, and effective and, thus, the preferred irrigation fluid. Warmed lactated Ringer's solution is theoretically preferable to normal saline as an ocular irrigant because it has a more physiologic pH and osmolarity. Immediate ophthalmologic referral is recommended for all but the most trivial chemical burns to the eye. Specific treatments for decontamination depend on the underlying agent. Chemical burns of the skin usually occur accidentally. Initial treatment consists of copious water lavage commencing at the scene and removal of particles. While most caustic injuries are treated symptomatically, exposures to hydrofluoric acid (HFA) frequently necessitate specific topic, subcutaneous, intralesional, intravenous or intraarterial injections of calcium gluconate to bind fluoride ions until analgesia. A burn from HFA that involves more than 5% of total body-surface area, or more than 1% of total body-surface area if the concentration of HFA is greater than 50%, requires admission to an ICU for electrocardiographic monitoring and serial measurements of calcium levels, since life-threatening arrhythmias and hypocalcemia can occur. Caustic injuries of the gastrointestinal tract can occur due to inadvertent ingestion of mislabelled fluids or as a suicidal attempt. Ingestion of alkalis is generally thought to result in more severe injuries than ingestion of acids. The oropharynx needs to be first examined by laryngoscopy. A supraglottic or epiglottic burn with erythema and edema formation may be a harbinger of airway obstruction and should be seen as an indication of early endotracheal intubation or tracheostomy. Endoscopy should be performed preferably within 12 hours and generally not later than 24 hours and can serve as a prognostic tool to manage patients appropriately. The risk of procedure related perforation is generally accepted to be negligible. Existing data fail to support the routine use of steroids and antibiotics to prevent esophageal stricture formation and may mask signs of peritonitis. Esophageal strictures, stenosis or gastric outlet obstruction are formidably long-term complications. There is a 1000- to 3000-fold increase in the incidence of esophageal carcinoma after lye-ingestion with a latent period between the time of ingestion and the development of carcinoma as long as 60 years. Endoscopic dilatation or insertion of intraluminal stents should not be performed within the first 6 weeks. Patients with grade 3b injuries may underwent prompt surgical resection in single cases, even if no perforation is confirmed. Perforation, evolution of a mediastinitis or peritonitis with multi-organ failure are devastating complications with extremely high mortality and warrants immediate surgical treatment.

Vitamin D Deficiency in Critically Ill Patients

To the Editor: Vitamin D deficiency is rarely considered or treated in critically ill patients. However, we recently reported three cases of life-threatening hypocalcemia secondary to vitamin D deficiency,1,2 highlighting potential acute complications. The prevalence of vitamin D deficiency and its significance in the intensive care unit (ICU) are unknown. We performed a prospective study of the vitamin D status in ICU patients (Table 1) referred to the Department of Endocrinology, St. Vincent's Hospital, Sydney, between January 2007 and January 2008. Demographic, physiological, and biochemical variables were recorded, including the Simplified Acute Physiology Score II (SAPS II) (on a . . .

Pulseless electrical activity after rapid administration of fresh frozen plasma

We present two extreme low birthweight preterm neonates who developed pulseless electrical activity during dilutional exchange transfusions with fresh frozen plasma (FFP). Both were polycythaemic recipient twins delivered prematurely because of foetal compromise as a result of twin-to-twin transfusion syndrome. The two events were associated with an acute fall in ionised calcium. We discuss the mechanism of these cardiac arrests and highlight the care required when infusing citrate containing blood products, particularly FFP, in order to avoid causing acute life-threatening hypocalcaemia.

Hypocalcaemia following therapy of thyrotoxicosis in an infant

A 2-mo-old infant born to a mother with Graves' disease and having symptoms of thyrotoxicosis was started on antithyroid drugs. Life-threatening hypocalcaemia requiring high-dose calcium infusions developed 1 mo after starting therapy. Serum alkaline phosphatase and paratharmone levels were elevated. This communication may serve to alert treating physicians about this rare complication in infants with thyrotoxicosis after initiation of antithyroid therapy. Severe hypocalcaemia may follow initiation of antithyroid therapy in infants with thyrotoxicosis.

Continuous Renal Replacement Therapy in the Initial Management of Neonatal Hyperammonemia Due to Urea Cycle Defects

After completing this article, readers should be able to: 1. Describe the metabolic acidosis that may be seen in urea cycle defects. 2. Delineate the most important factor in determining neurologic outcome in urea cycle defects. 3. Explain the factors that affect the blood ammonia concentration in continuous renal replacement therapy (CRRT). 4. Delineate the most difficult issue in pursuing CRRT in neonates. 5. Describe the morbidities associated with CRRT. MP was born at 39 weeks' estimated gestational age by vaginal delivery to a 35-year-old gravida 3 para 2 woman who had an uncomplicated pregnancy. The 3- and 6-year-old female siblings of the patient were healthy. Apgar scores were 8 at 1 minute and 9 at 5 minutes. The newborn was discharged to home after a 2-day stay in the well baby nursery during which time she appeared to be alert and was breastfeeding appropriately. She presented to the emergency department less than 1 day later after her parents noted increasing lethargy and very poor feeding at home. She was admitted to the neonatal intensive care unit (NICU). Results of a complete blood count with differential count and C-reactive protein evaluation were unremarkable, but the patient progressed to worsening lethargy, respiratory failure, and abdominal distension requiring intubation within hours of admission. The anterior fontanelle was soft on admission physical examination. Further testing revealed a base deficit of 6.1 on arterial blood gas, serum ammonia level of 810 mcmol/L (1,134 mcg/dL), serum lactate level of 5.6 mmol/L (5.6 mEq/L), and serum pyruvate level of 0.06 mmol/L. Results of liver function tests were abnormal, and the infant had a prothrombin time of 35.9 seconds, a partial thromboplastin time of 54.3 seconds, and a fibrinogen concentration of 1.75 g/L (175 mg/dL). Genetic and nephrology consultations were requested immediately. Additional metabolic studies were obtained, including measurement of plasma amino …

Hypocalcemia in End-Stage Renal Disease: A Consequence of Spontaneous Parathyroid Gland Infarction

Advances over the last several years have led to a better understanding of the etiology of hyperparathyroidism in renal disease and to more effective means of medical prevention and therapy. Thus, in most dialysis populations, many of the serious complications, such as bone fractures, refractory hypercalcemia, and hyperphosphatemia with vascular and other extraskeletal calcifications, have diminished. Furthermore, more aggressive medical management has decreased the requirement for parathyroidectomy. Unfortunately, not all patients respond to medical management and few still develop refractory hyperparathyroidism with associated morbidity. Of the many complications of refractory hyperparathyroidism in dialysis patients, the development of life-threatening hypocalcemia has not been described. We describe a patient with severe secondary hyperparathyroidism who presented with the acute development of hypocalcemia. To our knowledge, this represents the fourth case, the first reported in a patient with end-stage renal disease, of parathyroid autoinfarction presenting as acute hypocalcemia.