A long case of hypoparathyroidism ..

1. A 14-YEAR- OLD BOY PRESENTED
WITH ABNORMAL MOVEMENT
DR.HASAN AL BANNA
PHASE- A STUDENT
CRITICAL CARE MEDICINE
MEDICINE UNIT 4
DHAKA MEDICAL COLLEGE

2. Md. Ryhan Kabir, 14 years old, madrasa student, hailing
from Sokhipur, Tangail, was admitted in this hospital on
03/04/2018 at 12:00 pm with the complaint of :
- Repeated abnormal movement hands & feet for 4
months

3. History of Present Illness
According to mother’s statement, patient was resonably
well about 4 months back. Then suddenly developed
vacant stare with stiffening of whole body, spontaneous
repeated spasm of fingers, wrists, ankles, neck and
backwards bending of trunk with harsh sound production.
It occurs 2-3 times in a day both in day & night, lasts for 1-2
minutes, accompanied by tingling and numbness in hands

4. and feet, mild headache, bodyache, feverish feeling,
occasional drowsiness and lethargy in the absence of
tongue bite, bowel and bladder incontinence or loss of
consciousness and got spontaneous recovery. For the last
3 days the duration and frequency of attack was
increased. He had similar type of several episodes in his
first 2 years of life in an irregular interval and got

5. improvement without treatment and remain
asymptomatic for the last 12 years. He gave no history of
jaundice, blood transfusion, bony deformity, early morning
headache or vomiting, visual disturbance, palpitation, neck
surgery or taking any diuretics. He is non-diabetic non
hypertensive and his bowel-bladder habit is normal.

6. He had a history of fall from tree and head injury 7 years back,
treated by local physician at home and recovered. He has no
previous history of thyroid surgery. At the age of 7 months, had an
episode of generalized swelling of the body with complete recovery
withouttreatment.
History of Past Illness

7. Treatment History
He took following drugs for last 1 month irregularly and
have some improvement-
Sodium valproate
lamotrigine
Oral calcium
Antibiotic

8. Personal and Socioeconomic history
Non-smoker, non-alcoholic, belongs to low socioeconomic
condition, lives in a tin-shed house, drink arsenic free tube-
well water.

9. Family History
He is the second issue of his non-consanguineous
parents. All siblings are in good health. There is no such
type of illness in his family.

10. Immunization History
He was immunized as per EPI schedule.

11. Delivered at home through spontaneous NVD. Have no
history of delayed or obstructed labour. His milestone of
development was normal according to age.
Birth & Development History

12. GENERAL EXAMINATION

13. Appearance -illlooking
Decubitus -Onchoice
BodyBuilt -Average
Nutritionalstatus -Average
Anaemia -Mild
Jaundice -Absent
Cyanosis -Absent
Dehydration -Absent
Oedema -Absent
Clubbing -Absent
Koilonychia -Absent
Leoconychia -Absent

14. Lymphnode -Notpalpable
JVP -Notraised
Thyroidgland -Notenlarged
RR -18breaths/min
Temperature -98◦F
Pulse -84bpm,regular
BP -110/60 mmHg (on lying)
-100/60 mmHg (on standing)
-No postural drop

15. Anthropometric measurement
Height =143 cm
upper segment 72 cm
lower segment 71 cm
Arm span =140 cm
Weight =38 kg
BMI =18.6 kg/m2

16. SYSTEMIC EXAMINATION

17. Neurological Examination
• Higher psychic function and speech -Normal
• Cranial nerves with fundoscopy -Normal
• Motor function -Intact
• Sensory function -Intact
• Cerebellar function -Intact
• Signs of meningeal irritation -Absent
• Gait -Normal

18. Special Examination
Trousseau’s sign -Present
Chvostek’s sign -Present

19. Musculoskeletal System
•Bones : No bony deformity seen
•Muscles : No muscle wasting
•Joints: bilateral-
Flexion of metacarpophalageal joints of fingers
Extension of interphalageal joints
Adduction of thumb
Pedal spasm
•Spine :Normal

20. Alimentary System
Oral cavity:
Tongue, teeth, gum and buccal mucosa appears normal
Abdomen proper:
• Size and shape of abdomen is normal
• Umbilicus is centrally placed, inverted
• No visible veins or skin changes
• Liver, Spleen, Kidney not palpable
• No abdominal lymphadenopathy
• Percussion note of abdomen –Tympanitic& no signs of
ascitis
• Bowel sound Present

21. Eye Examination
Cataract and Kayser-Fleischer ring was not detected on
clinical and slit lamp examination.

22. ALL other systemic examinations found normal.

23. Salient Features
Md. Ryhan Kabir, a 14-year-old student, normotensive,
non-diabetic presented with suddenly developed vacant
stare with stiffening of whole body, repeated carpo-pedal
spasm and stridor for 4 months. It was episodic, occurs
2-3 times in a day both in rest and activities, lasts for 1-2
minutes, accompanied by tingling and numbness in hands
and feet, headache, bodyache, drowsiness without

24. association of tongue bite, bowel and bladder
incontinence or loss of consciousness. It resolved
spontaneously but for the last 3 days the duration and
frequency of attack was increased. He had similar type
of several episodes in his first 2 years of life in an
irregular interval and got improvement without
treatment and remain asymptomatic for the last 12

25. years. He was treated by anti-convulsents and oral
calcium for last 1 month irregularly and got some
improvement. He gave no history of jaundice, blood
transfusion, bony deformity, early morning headache or
vomiting, visual disturbance, palpitation, neck surgery or
taking any diuretics. He is normotensive, non-diabetic and
his bowel-bladder habit is normal. There is no history of

26. consanguity of marriage and such type illness in his family.
His birth and milestone of development was uneventful.
On examination, he was ill looking, mildly
anaemic, his pulse 84 beats/min, regular, BP-100/60mmHg
with no postural drop, Temp-98°F, Resp. rate was 18
breaths/min, trousseau’s sign and chvostek’s sign were
present. All other examination shows no abnormalities.

27. Provisional Diagnosis
???

28. Hypocalcaemic tetany
due to Hypoparathyroidism

29. Differential Diagnosis
Vitamin D deficiency
Epilepsy
Wilson’s Disease

30. I N V E S T I G A T I O N

31. CBC 03/0/18 05/04/18 Reference value
Hb 10.8 10.1 13-17gm/dl
ESR 22 - 0-12 mm in 1st hour
RBC 5.4 4.6 4.04- 6.13 million/dl
TC 11000 6000 4200-11000/mm3
Platelet 410000 300000 150000-450000/mm3

32. PBF
RBC Microcytic hypochromic cells,
Fair number of target cells,
Some pencil with elongated cells
WBC Mature, average count
PLATELET Adequate
COMMENT Microcytic hypochromic anemia

33. URINE R.M.E 3/4/18
ALBUMIN +
SUGER NIL
PUS CELL 2-4
RBC NIL
CAST & CRYSTALS ABSENT

34. S.ELECTROLYTES 21/4/18 5/4/18 3/4/18 Reference value
Na+ 141 136 137 136-148 mmol/l
K+ 4.04 3.9 4.04 3.8-5.2 mmol/l
Cl- 100 94 95 95-105 mmol/l
HCO3
-
21 - 16 22-28 mmol/l
T-CO2 23 27.7 18 24-28 mmol/l

35. OTHERS 30/4/18 5/4/18 3/4/18 Reference value
Total protein 7.0 6.3-8.2 gm/dl
S.ALBUMIN 4.5 3.8 3.2 3.6-5.2 gm/dl
S. Globulin 2.5 1.6-3.5 gm/dl
A:G ratio 1.8 : 1 (1.12-2.5):1

36. OTHERS 30/4/18 21/4/18 5/4/18 3/4/18 Reference value
S.Ca2+ 8.0 7.32 4.8(cc5) 6.28(cc7.0) 8.5-10.5mg/dl
S.PO4
3- 7.0 8.5 11.8 2.5-5 mg/dl
PTH 9.0 12.9 14 9-80 pg/dl
VIT-D 24.2 22.2 20-50 ng/ml
S.Mg2+ 1.85 1.8 1.7 1.6-2.3 mg/dl

37. OTHERS 30/4/18 21/4/18 16/4/18 Reference
value
S.CREATININE 0.94 0.8 0.6-1.3 mg/dl
S.Urea 30 - 10-50 mg/dl
SGPT 41 Up to 40 IU
24h URINARY Cu < 20 < 100 µg/l
24h URINARY Ca 47 29 100-300 mg/24h
S.Ceruloplasmin 153.48 200-600 µg/l

38. OTHERS 18/4/18 Reference value
FT3 4.40 2.77-5.27 pg/ml
FT4 1.00 0.77-2.0 ng/ml
hTSH 1.20 0.70-5.7 uIU/ml
S.Iron 112.54 49-181 µg/dl
TIBC 356 291-430 µg/dl
S.Ferritin 72.12 7-172 ng/ml

39. I M A G I N G

40. X-ray Rt & Lt hand A/P view

41. CT scan of Head shows hyperdense lesions involving the putamen, globus
pellidus, internal capsule, caudate neucleus, thalamus and centrum semiovale

43. MRI of Brain shows bilateral hyperintense lesions involving the basal ganglia

45. EEG
Normal EEG recorded.

46. USG of neck shows suggestive of bilateral inferior parathyroid cysts
(Lt side-3.4x2.8 mm,Rt side- 4.1x3.5 mm)
LT inf PTH RT inf PTH

47. • Childhood convulsion with a long asymptomatic
interval and re-symptomatic for last 4 months
• History of head injury in the interval period
• Treated as Epilepsy/?Wilson’s disease with little
improvement
Problem List

48. • S.Ca2+ decreased
• PO4
3- increased
• PTH & Vit-D hormone lower normal
• 24hs Urinary Ca2+ decreased
• 24h Urinary Cu = normal
• S.Ceruloplasmin
• Basal ganglia calcification in CT scan
• Bilateral parathyroid cyst in USG

49. Confirmatory Diagnosis
Primary Hypoparathyroidism
due to
non functional parathyroid cyst

50. Treatment
• 50 ml 10% Calcium gluconate + 500ml N/S
I.V @ 15 drops/min for 5 days followed by
• Oral calcium :3000 mg/day in 3 divided dose
• Activated Vitamin D:0.50 µg/day in 2 divided dose
• I.V MgSO4 daily for 5 consecutive days