An Unusual case of Tetany


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An Unusual case of Tetany

  1. 1. An unusual ca(u)se of tetany Prof. S.SUNDAR’s unit, Dr. N.ARUN KUMAR, PG
  2. 2. Case presentation <ul><li>Chitra 42/f – home-maker </li></ul><ul><li>Admitted with the </li></ul><ul><li>c/o tonic contractions of both the ULs -10 days </li></ul>
  3. 3. h/o presenting illness <ul><li>Pt was apparently normal till 1 year back </li></ul><ul><li>c/o tonic contractions of both ULs </li></ul><ul><li>-around 10 episodes over past 1 year </li></ul><ul><li>Increased frequency –for past 10 days </li></ul><ul><li>After developing each episodes –taken parenteral drug in private hospital & got relieved of the symptom </li></ul><ul><li>No investigations done </li></ul><ul><li>h/o generalized weakness & easy fatiguability </li></ul>
  4. 4. <ul><li>Not associated with LOC </li></ul><ul><li>No h/o tonic clonic movement </li></ul><ul><li>No h/o tongue bite </li></ul><ul><li>No h/o aspiration </li></ul><ul><li>No h/o bladder / bowel incontinence </li></ul><ul><li>No h/o aura </li></ul><ul><li>No h/o fever </li></ul><ul><li>No h/o abdominal pain </li></ul>
  5. 5. Past history <ul><li>Not a k/c of HTN/DM/CVA/CAD/seizures/PT </li></ul><ul><li>Not a k/c of hypo/hyperthyroidism </li></ul><ul><li>No h/o major surgery </li></ul><ul><li>No h/o chronic drug intake </li></ul><ul><li>No h/o neck irradiation </li></ul>
  6. 6. <ul><li>Personal history </li></ul><ul><li>Mixed diet intaker </li></ul><ul><li>Normal regular menstrual cycles </li></ul><ul><li>Family history </li></ul><ul><li>No relevant family history </li></ul>
  7. 7. General examination <ul><li>Conscious, oriented, afebrile </li></ul><ul><li>No pallor/cyanosis/icterus/clubbing/PE/GLA </li></ul><ul><li>Vitals: PR-84/min; BP- 110/80 mmHg; RR-18/min; temp- 36.4 </li></ul>
  8. 8. Systemic examination <ul><li>CVS- S1, S2 heard, no murmur </li></ul><ul><li>RS- NVBS +, no added sounds </li></ul><ul><li>Abdomen- soft; no organomegaly </li></ul><ul><li>CNS- NFND </li></ul>
  9. 9. Provisional diagnosis <ul><li>TETANY FOR EVALUATION </li></ul>
  10. 10. Investigations CBC Values Hb TC DC ESR RBC HCT Platelet MCV MCH MCHC 11.8 gm% 11000 cells/cumm P51, L38, E6, M4, B1 4/10 4.4 million 34.9% 4.84 lakh 79.3 fl 26.8 pg 33.8 gm/dl
  11. 11. Electrolytes ELECTROLYTES VALUES Serum calcium- Serum magnesium Serum Na Serum K- Serum chloride Serum HCO3 Serum PTH Serum albumin 5.7 mg% (N – 8.7-10.2mg%) 1.2 mg% (N – 1.5-2.3mg%) 134 meq/L 2.92 meq/L 84 meq/L 34 meq/L 9.5 pg/ml (N – 8-51 pg/ml) 3.8gm/dl
  12. 12. ABG <ul><li>pH 7.486 </li></ul><ul><li>HCO3 30.9 </li></ul><ul><li>pCO2 41.8 </li></ul><ul><li>K 1.26 mmol/L </li></ul><ul><li>Metabolic alkalosis </li></ul>
  13. 13. <ul><li>24 hour urine Ca 46.2 mg (N – 100-321mg) </li></ul><ul><li>24 hour urine Cl 323 meq (N – 110-250meq) </li></ul><ul><li>RBS 77 mg% </li></ul><ul><li>Blood urea 22 mg% </li></ul><ul><li>Serum creatinine 1.0 mg% </li></ul><ul><li>ECG – prolonged Q-T interval </li></ul>
  14. 14. DIAGNOSIS <ul><li>GITELMAN’S SYNDROME </li></ul>
  15. 15. Gitelman’s syndrome <ul><li>Autosomal recessive condition also characterized by hypokalemic metabolic alkalosis, but with hypocalciuria & hypomagnesemia </li></ul>
  16. 16. Pathogenesis of Gitelman’s syndrome Inactivating mutations in the gene downregulation Hypocalciuria Due to associated Plasma volume contraction
  17. 17. Clinical features Gitelman’s syndrome is mostly a disorder of adults
  18. 18. Laboratory evaluation
  19. 19. Treatment <ul><li>Magnesium aspartate (5-15 mmol Mg/day) </li></ul><ul><li>Magnesium oxide </li></ul><ul><li>Potassium supplements </li></ul>
  20. 20. Causes of hypocalcemia Low PTH levels High PTH levels Parathyroid agenesis isolated DiGeorge syndrome Vit. D def or impaired 1,25(OH)2 production/action nutritional vit.D def renal insufficiency with impaired 1,25(OH)2 production vit. D resistance Parathyroid destruction surgical radiation infiltration by mets auto immune PTH resistance syndromes PTH receptor mutations pseudo hypoparathyroidism Reduced parathyroid function hypomagnesemia activating CaSR mutations Drugs calcium chelators inhibitors of bone resorption (bisphosphonates, plicamycin) altered vit. D metabolism (phenytoin, ketoconazole) Miscellaneous causes acute pancreatitis acute rhabdomyolysis hyngry bone syndrome osteoblastic mets (Ca prostate)
  21. 21. Causes of hypocalcemia Associated with normal / low plasma PO4 Associated with high plasma PO4 Associated with hypoalbuminemia Vit. D def decreased intake decreased absorption (post-gastrectomy, PBC, intestinal malabsorption) Idiopathic or sporadic hypoparathyroidism Hemodilution Decreased 25(OH) vit. D generation (liver disease, anti- convulsants) Post operative hypo-parathyroidism Nephrotic syndrome Decreased calcitriol renal failure type 1 vit. D dep rickets Acquired hypo- parathyroidism post irradiation amyloidosis Exudative enteropathy Resistance to calcitriol type 2 vit. D dep rickets Pseudo hypo- parathyroidism type 1 type 2 cirrhosis Acute pancreatitis CKD advanced stage Mg deficiency AKI oligoanuric nstage
  22. 22. Clinical features <ul><li>Symptoms of hypocalcemia depend on </li></ul>RAPIDITY SEVERITY
  23. 23. <ul><li>Fatigue & muscular weakness </li></ul><ul><li>Increased irritability </li></ul><ul><li>Loss of memory </li></ul><ul><li>Confusion, hallucination, paranoia, depression </li></ul><ul><li>ECG manifestation of prolonged Q-T interval </li></ul>
  24. 24. Trousseau’s sign: carpal spasm induced by inflation of BP cuff to >20 mmHg of systolic BP for 3 min
  25. 25. Chvostek’s sign: tapping of facial nerve branches  twitching of facial muscles)
  26. 26. Acute hypocalcemia paraesthesias of the lips & extremities muscle cramps tetany laryngeal stridor convulsions
  27. 27. Chronic hypocalcemia cataracts brittle nails with transverse grooves dry skin decreased or even absent axillary & pubic hair
  28. 28. Diagnostic approach to hypocalcemia <ul><li>Mesurement of serum Ca </li></ul><ul><li>Measurement of serum PO4, Mg </li></ul>
  29. 29. Diagnostic approach to hypocalcemia
  30. 32. Treatment of hypocalcemia <ul><li>Depends on </li></ul>RAPIDITY SEVERITY ACCOMPANYING COMLICATIONS
  31. 33. Treatment of acute symptomatic hypocalcemia <ul><ul><li>Promptly correct symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany with parenteral administration of calcium salts. </li></ul></ul><ul><ul><ul><li>Administer 1-2 ampules 10% calcium gluconate (93 mg/10 mL) in 50-100 mL of D5W over 5-10 minutes. Calcium chloride 10% solution (273 mg/10-mL ampule) delivers higher amounts of calcium and is advantageous when rapid correction is needed, but it should be administered via central venous access. </li></ul></ul></ul><ul><ul><ul><li>Measure serum calcium every 4-6 hours to maintain serum calcium levels at 8-9 mg/dL. If low albumin is also present, ionized calcium should be monitored. </li></ul></ul></ul>
  32. 34. Treatment of acute symptomatic hypocalcemia (contd…) <ul><ul><li>Patients with cardiac arrhythmias or patients on digoxin therapy need continuous ECG monitoring during calcium replacement because calcium potentiates digitalis toxicity. </li></ul></ul><ul><ul><li>Identify and treat the cause of hypocalcemia and taper the infusion. </li></ul></ul><ul><ul><li>Start oral calcium and vitamin D treatment early. Patients with postparathyroidectomy hungry bone disease, especially those with osteitis fibrosa cystica, can present with a dramatic picture of hypocalcemia. </li></ul></ul>
  33. 35. Treatment of chronic hypocalcemia: Treatment in PTH deficiency <ul><ul><li>Patients with hypoparathyroidism and pseudo-hypoparathyroidism can be managed initially with the oral administration of calcium supplements. </li></ul></ul><ul><ul><li>The hypercalcemic effects of thiazide diuretics may offer some additional benefits. </li></ul></ul><ul><ul><li>In patients with severe hypoparathyroidism, vitamin D treatment may be required; however, remember that PTH deficiency impairs the conversion of vitamin D to calcitriol. </li></ul></ul><ul><ul><li>Therefore, the most efficient treatment is the addition of 0.5-2 mcg of calcitriol or 1-alpha-hydroxyvitamin D3. </li></ul></ul>
  34. 36. Treatment of chronic hypocalcemia (contd…) <ul><ul><li>Nutritional vitamin D deficiency from lack of sunlight exposure or poor oral intake of vitamin D: Ultraviolet light or sunlight exposure can treat these patients. </li></ul></ul><ul><ul><li>Treat nutritional rickets with vitamin D2. Oral calcium preparations containing 1-2 g of elemental calcium per day can treat patients with a calcium deficiency. </li></ul></ul><ul><ul><li>Calcitriol may be used, but it has the disadvantages of a higher price and the possibility of producing hypervitaminosis D with hypercalcemia. </li></ul></ul>
  35. 37. Goal of treatment To bring serum calcium to low normal range To avoid hypercalciuria To avoid nephrolithiasis