Today we discussed hypocalcemia. A few points:
Clinical manifestations:
-Paresthesias
-Lethargy
-Seizures
-possibly arrhythmias (lengthens QT)
-Chvostek's sign:
Tap cheek 2cm anterior to tragus, look for ipsilateral upper lip twitch
NB- this video is freely available on YouTube, and is not a patient cared for in this hospital
-Trousseau's sign:
Inflate BP cuff above systolic pressure for 3 minutes, look for painful carpal spasm (shown above)
An approach to causes of hypocalcemia (which drives appropriate history, physical, and investigations):
Think of major determinants of calcium handling, and what can affect each:
Low PTH:
-iatrogenic (most common cause); e.g. post-thyroidectomy
-autoimmune (can be part of autoimmune polyendocrine syndrome with vitiligo and candidiasis)
-infiltration of the parathyroids (sarcoid, hemochromatosis)
-hypomagnesemia (alters PTH receptor sensitivity)
Low Vitamin D:
-malabsorption of fat-soluble vitamins (ADEK)
-liver disease
-kidney disease
-inadequate sun exposure
GI tract:
-malabsorption of calcium (proximal small bowel): celiac, Crohn's, others in addition to vit D malabsorption
Kidneys:
-Loop diuretics
-Calcium wasting: Fanconi's syndrome (proximal tubular reabsorption problem; causes hypocalcemia, hypophosphatemia, non-anion gap metabolic acidosis, hypoglycemia, hypoalbuminemia)
Bone:
-"Hungry bone syndrome"- post parathyroidectomy after hyperparathyroidism, increased bone uptake of calcium after prolonged calcium "leaching"
-osteoblastic metastases (esp. prostate, breast)
Intravascular Ca binding:
-citrate (e.g. in dialysis or massive transfusion)- binds ca
-hyperphosphatemia
Calcium deposition sites:
-severe pancreatitis
-rhabdomyolysis
Others:
-secondary hyperparathyroidism; often have normal or low Ca in renal failure for many reasons
-DiGeorge syndrome- affects PTH receptor
-Bartter's syndrome- acts like a loop diuretic causing calciuresis
-"pseudohypoparathyroidism"- looks like hypoparathyrodism, except PTH is high; receptor mutation
Tip: The phosphate level can be quite helpful in sorting out causes; PTH increases calcium and decreases phosphate. Vitamin D increases both calcium and phosphate.
Link:
Click here for a NEJM review of hypoparathyroidism that discusses much of above
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