Hypomagnesaemia leading to parathyroid dysfunction, hypocalcaemia, and hypokalaemia as a complication of long-term treatment with a proton pump inhibitor - a literature review.

Proton pump inhibitors (PPIs) are one of the most frequently used medications worldwide. The side effects of this class of drugs have been widely studied. However, their impact on the electrolyte balance is frequently forgotten. Long-term PPI administration can lead to profound electrolyte disturbances, namely hypomagnesaemia as well as, secondary to very low magnesium levels, hypocalcaemia and hypokalaemia. In this paper we comprehensively review the complexity of the mechanisms contributing to electrolyte imbalance following PPI (proton pump inhibitors) by changing the pH in the intestinal lumen, interfering with the active cellular transport of magnesium regulated by the transient receptor potential melastatin cation channels TRPM6 and TRPM7. The accompanying hypomagnesaemia causes unblocking of the renal outer medullary potassium channel (ROMK), which results in increased potassium loss in the ascending limb of the loop of Henle. Hypokalaemia caused by hypomagnesaemia is resistant to potassium supplementation because the loss of this element in urine increases with the supply of potassium. Additionally, within the calcium-sensitive receptor (CASR), dissociation of magnesium from the alpha subunit of G protein caused by hypomagnesaemia increases its activity, leading to inhibition of PTH secretion and hypocalcaemia resistant to calcium supplementation. All this means that in some patients, chronic use of proton pump inhibitors by affecting the absorption of magnesium, may lead to life-threatening electrolyte disorders.

Post-craniopharyngioma surgery hypocalcemia due to denosumab use for osteoporosis: A case report.

RATIONALE: Denosumab, a fully humanized IgG monoclonal antibody, is commonly employed in the management of different types of osteoporosis. Up to now, hypocalcemia linked with denosumab has been predominantly reported in dialysis patients suffering from chronic kidney disease. Interestingly, there have been no reports of hypocalcemia following craniopharyngioma surgery with the use of denosumab. PATIENT CONCERNS: A 65-year-old male received a subcutaneous injection of denosumab (60 mg) as a treatment for osteoporosis following the resection of a craniopharyngioma. Remarkably, the patient developed hypocalcemia within 4 days post-injection. However, 6 months subsequent to the initial treatment, the patient underwent another subcutaneous injection of desmuzumab and once again experienced hypocalcemia. DIAGNOSES: Hypocalcemia. INTERVENTIONS: The hypocalcemia was successfully managed with intravenous calcium gluconate and oral calcium carbonate D3 tablets, leading to the alleviation of symptoms. OUTCOMES: Hypocalcemia following the use of denosumab after craniopharyngioma surgery is rare, and its occurrence may be associated with the primary disease and concomitant medications. LESSONS: It underscores the necessity for clinicians to perform a thorough evaluation of the patient's overall health status, complete all requisite testing, pay particular attention to those in high-risk categories, and ensure serum calcium levels are monitored, along with conducting other essential tests, prior to and following each administration of denosumab.

Postoperative hungry bone syndrome in primary hyperparathyroidism: A case report.

RATIONALE: Hungry bone syndrome (HBS) is a forgotten and underdiagnosed cause. Postoperative HBS refers to patients with high bone turnover before surgery, but after surgery, the inhibition of osteoclast resorption by intact parathyroid hormone suddenly decreases, resulting in a sudden increase in the amount of calcium resorbed by the bone, and a rapid, severe and persistent hypocalcemia, which may be accompanied by hypophosphatemia and hypomagnesemia. We present a case with information about HBS and related complications after parathyroidectomy (PTX). PATIENT CONCERNS: The patient was a 57-year-old woman who presented to the hospital with "pain in both ankles for more than 3 years and in both knees for more than 2 years." DIAGNOSES: A parathyroid mass was found preoperative. Unilateral resection of the lesion was performed under general anesthesia. On gross examination, the mass was reddish brown in color, about 2.9 × 2.5 × 2.3 cm, with abundant blood supply. Postoperative pathology diagnosed parathyroid adenoma. INTERVENTIONS: The patient was diagnosed with HBS on day 3 post-PTX, which lasted for 9 days. OUTCOMES: After active calcium supplementation and other pharmacological interventions, her test parameters gradually returned to normal and she was discharged on the 13th day after surgery. LESSONS: Using the case of a patient with primary hyperparathyroidism with HBS lasting 9 days after PTX for diagnosis and management, we aimed to summarize possible predictors and perioperative management strategies to reduce the incidence, severity, and duration of postoperative HBS.

Association between non-esterified fatty acids and calcium concentrations at calving with early lactation clinical diseases, fertility and culling in grazing dairy cows in Uruguay.

This study describes the association of non-esterified fatty acids (NEFA) and calcium concentrations at calving with early lactation disease, reproductive performance and culling in 646 dairy cows from 13 commercial grazing dairy herds in Uruguay. During one year, health events were recorded from calving to 30 days in milk (DIM). The first author visited each farm every 20 days. During each visit, body condition score (BCS) was recorded (scale 1-5), defining BCS < 3 as suboptimal and BCS > 3 as optimal, and a blood sample was taken from cows between 0 and 4 DIM for metabolite determination. To evaluate the association between health events (i.e., retained placenta-metritis and clinical mastitis) and risk factors (parity, BCS, high NEFA (> 0.6 mmol/L) and subclinical hypocalcemia (SCH) (< 2.10 mM)) data were analysed using multivariable logistic regression models. To evaluate the association of health events and risk factors with reproductive performance and culling, data were analysed using Cox proportional hazard regression models. A risk factor and an outcome of interest were assumed to be associated at P < 0.05 and a tendency to be associated was defined at P < 0.10. Overall, 47 % (n = 303) of the cows showed elevated NEFA concentration and 77 % (n = 499) had SCH. In addition, 21.5 % (n = 139) of the cows recorded at least one clinical disease. Cumulative incidence was 17 % (n = 109) for clinical mastitis, 4.2 % (n = 27) for retained placenta (RP)-metritis and 1.4 % (n = 7) for lameness. Clinical mastitis was associated with parity, with lower odds in primiparous (PP) cows (OR = 0.42, P < 0.01). Cows in an optimal BCS also tended to have lower odds (OR = 0.66, P = 0.07). Moreover, high NEFA and SCH cows had higher odds of CM (OR = 4.5, P = 0.01 and OR = 1.75, P = 0.04, respectively). Retained placenta-metritis tended to be associated with high NEFA concentration (OR = 2.2, P = 0.06). Primiparous cows with suboptimal BCS showed an increased first insemination rate (HR = 2.34; P < 0.01). The risk of culling was lower in PP cows (HR = 0.19; P < 0.01) and in cows with optimal BCS and low NEFA concentration (HR = 0.38; P = 0.03). Our data show that metabolic challenge (defined as peripartum suboptimal BCS, high NEFA or SCH) is associated with increased odds of clinical mastitis and RP-metritis, decreased probability of insemination and increased hazard of culling. Under grazing conditions, we suggest that farm management to improve the metabolic adaptation to lactation represents an opportunity to enhance cow performance in terms of health, fertility and longevity.

A Very Rare Side Effect of a Very Commonly Used Drug: Pantoprazole-induced Seizure.

Pantoprazole is an extensively used proton pump inhibitor (PPI) for acid peptic disease. PPI rarely cause hypomagnesemia. Hypomagnesemia is commonly associated with hypokalemia and hypocalcemia. Severe hypomagnesemia and hypocalcemia can cause seizures. Here, we report a patient on long-term pantoprazole who presented with generalized tonic-clonic seizures and had severe hypomagnesemia, hypocalcemia, hypokalemia, and secondary hyperparathyroidism. When patients on long-term PPI present with seizures, hypomagnesemia/hypocalcemia has to be excluded.

Electrolyte disorders related emergencies in children.

This article provides a comprehensive overview of electrolyte and water homeostasis in pediatric patients, focusing on some of the common serum electrolyte abnormalities encountered in clinical practice. Understanding pathophysiology, taking a detailed history, performing comprehensive physical examinations, and ordering basic laboratory investigations are essential for the timely proper management of these conditions. We will discuss the pathophysiology, clinical manifestations, diagnostic approaches, and treatment strategies for each electrolyte disorder. This article aims to enhance the clinical approach to pediatric patients with electrolyte imbalance-related emergencies, ultimately improving patient outcomes.Trial registration This manuscript does not include a clinical trial; instead, it provides an updated review of literature.

External Validation and Update of the Risk Prediction Model for Denosumab-Induced Hypocalcemia Developed From a Hospital-Based Administrative Database.

PURPOSE: Denosumab is used to treat patients with bone metastasis from solid tumors, but sometimes causes severe hypocalcemia, so careful clinical management is important. This study aims to externally validate our previously developed risk prediction model for denosumab-induced hypocalcemia by using data from two facilities with different characteristics in Japan and to develop an updated model with improved performance and generalizability. METHODS: In the external validation, retrospective data of Kameda General Hospital (KGH) and Miyagi Cancer Center (MCC) between June 2013 and June 2022 were used and receiver operating characteristic (ROC)-AUC was mainly evaluated. A scoring-based updated model was developed using the same data set from a hospital-based administrative database as previously employed. Selection of variables related to prediction of hypocalcemia was based on the results of external validation. RESULTS: For the external validation, data from 235 KGH patients and 224 MCC patients were collected. ROC-AUC values in the original model were 0.879 and 0.774, respectively. The updated model consisting of clinical laboratory tests (calcium, albumin, and alkaline phosphatase) afforded similar ROC-AUC values in the two facilities (KGH, 0.837; MCC, 0.856). CONCLUSION: We developed an updated risk prediction model for denosumab-induced hypocalcemia with small interfacility differences. Our results indicate the importance of using data from plural facilities with different characteristics in the external validation of generalized prediction models and may be generally relevant to the clinical application of risk prediction models. Our findings are expected to contribute to improved management of bone metastasis treatment.

Role of Postoperative Intact Parathyroid Hormone Levels in Predicting Hypocalcaemia after Thyroidectomy.

OBJECTIVE: To determine the sensitivity and specificity of intact parathyroid hormone (iPTH) levels in predicting hypocalcaemia after thyroidectomy. STUDY DESIGN: A descriptive cross-sectional study. Place and Duration of the Study: Department of General Surgery, Shifa International Hospital and Shifa Foundation, Islamabad, from May 2021 to 2022. METHODOLOGY: The sample size was calculated to be 205 with consecutive non-probability sampling. Serum iPTH levels and serum calcium levels were measured postoperatively at 6 hours and 24 hours and recorded in a proforma for analysis. After collection, the data were entered and analysed using SPSS version 24.0. RESULTS: Among 205 patients, 157 (76.6%) were females and 48 (23.4%) were males. At 6 hours postoperatively, 121 (59%) patients had normal iPTH levels and 123 (60%) patients had normal serum calcium levels (p = 0.15). At 24-hour, 130 (63.4%) patients had normal iPTH levels and 92 (44.9%) patients had normal serum calcium levels (p = 0.001). Overall, 8 (3.9%) patients developed symptomatic hypocalcaemia (p = <0.001). The sensitivity and specificity of iPTH levels at ≤15 pg/ml were 100% and 70%, respectively, but at 24 pg/ml cut-off level, the specificity increased to 90% with sensitivity of 100%. CONCLUSION: Low serum iPTH levels at 6 hours after surgery can predict hypocalcaemia in patients undergoing thyroidectomy, even if serum calcium levels appear normal at that time. KEY WORDS: Parathyroid hormone, Serum calcium, Hypocalcaemia, Total thyroidectomy, Calcium homeostasis.

Saline suppression testing-induced hypocalcemia and implications for clinical interpretations.

BACKGROUND: Extracellular calcium critically regulates physiologic aldosterone production. Moreover, abnormal calcium flux and signaling are involved in the pathogenesis of the majority of primary aldosteronism cases. METHODS: We investigated the influence of the saline suppression test (SST) on calcium homeostasis in prospectively recruited participants (n = 86). RESULTS: During SST, 100% of participants had decreases in serum calcium, with 48% developing frank hypocalcemia. Serum calcium declined from 2.30 ± 0.08 mmol/L to 2.13 ± 0.08 mmol/L (P < .001) with parallel increases in parathyroid hormone from 6.06 ± 2.39 pmol/L to 8.13 ± 2.42 pmol/L (P < .001). In contrast, serum potassium and bicarbonate did not change, whereas eGFR increased and serum glucose decreased (P < .001). Lower body surface area (translating to greater effective circulating volume expansion during SST) was associated with greater reductions in (ß = .33, P = .001), and absolutely lower, serum calcium levels (ß = .25, P = .001). When evaluating clinically-relevant diagnostic thresholds, participants with post-SST aldosterone levels <138 pmol/L had lower post-SST calcium and 25-hydroxyvitamin D levels (P < .05), and higher post-SST parathyroid hormone levels (P < .05) compared with those with post-SST aldosterone levels >277 pmol/L. CONCLUSION: SST uniformly decreases serum calcium, which is likely to be due to the combination of variable dilution, increased renal clearance, and vitamin D status. These acute reductions in bioavailable calcium are associated with lower post-SST aldosterone. Given the critical role of extracellular calcium in regulating aldosterone production, these findings warrant renewed inquiry into the validity of SST interpretations for excluding primary aldosteronism.

[Analysis of the efficacy and safety of bone disease treatment in patients with newly diagnosed multiple myeloma treated with denosumab or zoledronic acid].

Objective: This study investigated the efficacy and safety of denosumab (DENOS) versus zoledronic acid (ZOL) in the bone disease treatment of newly diagnosed multiple myeloma. Methods: The clinical data of 80 patients with myeloma bone disease (MBD) at the Fifth Medical Center of PLA General Hospital between March 1, 2021 and June 30, 2023 were retrospectively reviewed. Eighteen patients with severe renal impairment (SRI, endogenous creatinine clearance rate<30 ml/min) were treated with DENOS, and 62 non-SRI patients were divided into DENOS (30 patients) and ZOL group (32 patients) . Results: Hypocalcemia was observed in 26 (33%) patients, and 22 patients developed hypocalcemia during the first treatment course. The incidence of hypocalcemia in the non-SRI patients of DENOS group was higher than that in the ZOL group [20% (6/30) vs 13% (4/32), P=0.028]. The incidence of hypocalcemia in SRI was 89% (16/18). Multivariate logistic regression analysis revealed that endogenous creatinine clearance rate<30 ml/min was significantly associated with hypocalcemia after DENOS administration (P<0.001). After 1 month of antiresorptive (AR) drug application, the decrease in the serum ß-C-terminal cross-linked carboxy-telopeptide of collagen type I concentrations of SRI and non-SRI patients in the DENOS group were significantly higher than that in the ZOL group (68% vs 59% vs 27%, P<0.001). The increase in serum procollagen type Ⅰ N-terminal propeptide concentrations of patients with or without SRI in the DENOS group were significantly higher than that in the ZOL group (34% vs 20% vs 11%, P<0.05). The level of intact parathyroid hormone in each group increased after AR drug treatment. None of the patients developed osteonecrosis of the jaw and renal adverse events, and no statistically significant differences in the overall response rate, complete remission and stringent complete remission rates were found among the groups (P>0.05), and the median PFS and OS time were not reached (P>0.05) . Conclusions: In the treatment of MBD, DENOS minimizes nephrotoxicity and has strong AR effect. Hypocalcemia is a common adverse event but is usually mild or moderate and manageable.

Calcium Disorders.

This article provides a comprehensive overview of calcium physiology, clinical presentation with physical examination findings, laboratory assessment, differential diagnosis, and management of hypocalcemia and hypercalcemia for the primary care provider.

A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation.

BACKGROUND: Regional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH. METHODS: This is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time. RESULTS: We included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur. CONCLUSIONS: We describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules. TRIAL REGISTRATION: The study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.

Clinical protocol using calcium and calcitriol after paediatric total thyroidectomy decreases postoperative hypocalcaemia and inpatient blood tests.

INTRODUCTION: Postoperative hypocalcaemia is common after thyroidectomy. This study aimed to evaluate whether a standardised post-thyroidectomy protocol using prophylactic calcium and calcitriol reduces hypocalcaemia incidence after total thyroidectomy in children and adolescents. METHODS: A cohort children and adolescents ≤18 years of age undergoing total thyroidectomy between January 2016 and October 2022 in one institution were retrospectively identified and divided into pre-protocol and post-protocol groups. The primary outcome measure was hypocalcaemia (total serum calcium of <2.0 mmol/L; ionised serum calcium of 0.9 mmol/L). Secondary outcome measures were the occurrence of hypercalcaemia (serum Calcium >2.7 mmol/L; ionised calcium >1.31 mmol/L), length of hospitalisation and number of postoperative blood tests. RESULTS: There were 22 patients in each group (mean age 11.8; SD 4.3 years, female 36 %). The rate of hypocalcaemia was significantly higher in the pre-protocol group than the post-protocol group (54 % vs 13.6 %, p = 0.010). Patients in the pre-protocol group had more inpatient blood tests (mean 5.4; SD 3.2) than the post-protocol group (mean 3.3; SD 1.8, p = 0.011), although the total postoperative blood test count was similar between the groups. Six (13.6 %) patients developed hypercalcaemia. The rate of hypercalcaemia was similar between groups (pre-protocol 2, 9.1 %; post-protocol 4, 18.1 %; p = 0.664). Length of hospitalisation was similar between groups. CONCLUSION: Our standardized protocol decreased hypocalcemia and inpatient blood tests after total thyroidectomy in children. Future research should explore if incorporating preoperative calcium and calcitriol treatment, along with intraoperative PTH levels for risk management, can further reduce hypocalcemia rates in paediatric patients.

Association of different classifications of hypocalcemia with quantity and quality of colostrum, milk production, and health of Holstein dams and their calves.

The aim of the present study was to assess the effect of serum calcium (Ca) status in the early postpartum period on the quantity and quality of colostrum, milk production, and the health of Holstein dams and their calves. One hundred multiparous Holstein cows were enrolled in this study. To determine serum Ca status, blood samples were taken at 1 and 4 days in milk (DIM). Cows were categorized into 1 of 4 groups based on their serum Ca concentrations: normocalcemic (CON; Ca >1.87 at 1 DIM and >2.10 mmol/L at 4 DIM, n = 36), transient SCH (TSCH; Ca ≤1.87 at 1 DIM and >2.10 mmol/L at 4 DIM, n = 14), persistent SCH (PSCH; Ca ≤1.87 at 1 DIM and ≤2.10 mmol/L at 4 DIM, n = 15), or delayed SCH (DSCH; Ca >1.87 at 1 DIM and ≤2.10 mmol/L at 4 DIM, n = 35). The ROC curve was utilized to determine the optimal cut-off value for serum total Ca, maximizing both sensitivity and specificity in predicting metritis. Metabolic disorders such as dystocia, retained placenta, and culling within 60 DIM were not affected by serum Ca status in the early postpartum period (P > 0.10). However, the incidences of metritis and endometritis were different based on the serum Ca status of the cows. The PSCH cows had a higher incidence of metritis than the CON cows (P = 0.05). Also, the DSCH cows tended to have an increased risk of metritis than the CON cows (P = 0.09). However, metritis incidence in the TSCH and CON cows was similar (P = 0.83). Cows with PSCH (P = 0.07) and DSCH (P = 0.10) tended to be at a higher risk for endometritis than the CON cows. But, the incidence of endometritis in the TSCH and CON cows was not different (P = 0.50). The TSCH cows had higher milk yield than the PSCH and DSCH cows (P = 0.05). However, milk yield was not different between the TSCH and CON cows and the PSCH and DSCH and CON cows. The serum Ca status of cows had no effect on colostrum volume and its quality, age and weight of weaning, and average daily gain of calves (P > 0.10). The proportion of calves experiencing failure of passive transfer (FPT) was greater in the PSCH group than in the CON group (P = 0.03). Also, the FPT tended to be higher in the DSCH calves compared to the CON calves (P = 0.10). However, the FPT in the TSCH and CON calves was not different (P = 0.83). The incidence of diarrhea tended to be higher in the PSCH and DSCH calves compared to the CON calves (P = 0.10). However, diarrhea incidence between the TSCH and CON calves was similar (P = 0.97). Overall, the findings of this study suggest that cows with TSCH showed better adaptation to lactation, experienced a lower occurrence of diseases and produced higher milk compared to PSCH and DSCH cows. Furthermore, despite the similar quantity and quality of colostrum across all groups, the PSCH and DSCH groups displayed a greater proportion of calves experiencing FPT and diarrhea in comparison to the TSCH group.

Can baseline serum calcium levels predict outcomes of intracerebral hemorrhage? A systematic review and meta-analysis.

OBJECTIVE: The prognostic role of baseline calcium levels in patients with intracerebral hemorrhage (ICH) is conflicting. We aimed to conduct the first meta-analysis in the literature to examine if baseline calcium levels can predict outcomes after ICH. METHODS: English-language studies listed on the databases of Embase, PubMed, ScienceDirect, and Web of Science were searched up to 20th November 2023. Meta-analysis was conducted for baseline hematoma volume, hematoma expansion, unfavorable functional outcome, and mortality. RESULTS: Ten studies were included. Meta-analysis showed that patients with hypocalcemia have significantly higher baseline hematoma volume (MD: 8.6 95 % CI: 3.30, 13.90 I2 = 88 %) but did not have a higher risk of hematoma expansion (OR: 1.82 95 % CI: 0.89, 3.73 I2 = 82 %). Meta-analysis of crude (OR: 1.86 95 % CI: 1.25, 2.78 I2 = 63 %) and adjusted data (OR: 2.05 95 % CI: 1.27, 3.28 I2 = 64 %) showed those with hypocalcemia had a significantly higher risk of unfavorable functional outcomes. Meta-analysis of both crude (OR: 2.09 95 % CI: 1.51, 2.88 I2 = 80 %) and adjusted data (OR: 1.38 95 % CI: 1.14, 1.69 I2 = 70 %) also demonstrated a significantly higher risk of mortality in patients with hypocalcemia. CONCLUSION: Baseline serum calcium may have a prognostic role in ICH. Hypocalcemia at baseline may lead to large hematoma volume and poor functional and survival outcomes. However, there seems to be no relation between hypocalcemia and the risk of hematoma expansion. Further studies examining the role of calcium on ICH prognosis are needed.

From seizures to cognitive dysfunction: A case report of Fahr syndrome in an Afghan patient.

RATIONALE: Fahr syndrome is a rare, degenerative neurological condition characterized by bilateral idiopathic calcification of the periventricular region, especially the basal ganglia. This condition is often misdiagnosed as other neurological or psychiatric disorders due to its rarity and overlapping symptoms. PATIENT CONCERNS: A 34-year-old man had been experiencing seizures and cognitive dysfunction for few years, which were further compounded by slurred speech and motor difficulties as acute conditions. DIAGNOSIS: After investigations, severe hypocalcemia, and hypoparathyroidism were detected and his brain computed tomography showed extensive bilateral calcifications in basal ganglia, thalamus, dentate nuclei, and some parts of subcortical white matter, suggestive of Fahr syndrome. Although, the patient was initially misdiagnosed due to a lack of information and the rarity of this disease. INTERVENTION: The patient was treated with intravenous calcium gluconate, vitamin D3, l-ornithine l-aspartate syrup, and levetiracetam, replacing carbamazepine. OUTCOME: His symptoms, including slurred speech, muscle pain, and stiffness improved, serum calcium normalized, and he was discharged with medications for memory deficit and depression. LESSONS: This case underscores the importance of raising awareness among physicians, especially in areas with limited medical resources, about the significance of prompt diagnosis and appropriate symptomatic treatment in enhancing patient prognosis and quality of life.

Identification of novel risk factors for postoperative severe hypocalcemia in patients with primary hyperparathyroidism undergoing parathyroidectomy: a case control study.

BACKGROUND: Patients with primary hyperparathyroidism (PHPT) are at risk for severe hypocalcemia (SH) following parathyroidectomy (PTX), but limited data exist on the predictors of SH. We aimed to identify risk factors for early postoperative SH after PTX in patients with PHPT and to evaluate the predictive value of clinical parameters. METHODS: A retrospective review of patients with PHPT who underwent PTX between January 2010 and December 2022 was performed. A total of 46 patients were included in the study, with 15 (32.6%) experiencing postoperative SH, 19 (41.3%) having calculi in the ureter or kidney, and 37 (80.4%) having osteoporosis. Patients were divided into SH and non-SH groups based on postoperative serum calcium levels. Preoperative biochemical indicators, bone turnover markers, and renal function parameters were analyzed and correlated with postoperative SH. RESULTS: Statistically significant (P < 0.05) differences were found in preoperative serum calcium (serum Ca), intact parathyroid hormone, serum phosphorus (serum P), serum Ca/P, percentage decrease of serum Ca, total procollagen type 1 intact N-terminal propeptide, osteocalcin (OC), and alkaline phosphatase levels between the two groups. Multivariate analysis showed that serum P (odds ratio [OR] = 0.989; 95% confidence interval [95% CI] = 0.981-0.996; P = 0.003), serum Ca (OR = 0.007; 95% CI = 0.001-0.415; P = 0.017), serum Ca/P (OR = 0.135; 95% CI = 0.019-0.947; P = 0.044) and OC levels (OR = 1.012; 95% CI = 1.001-1.024; P = 0.036) were predictors of early postoperative SH. The receiver operating characteristic curve analysis revealed that serum P (area under the curve [AUC] = 0.859, P < 0.001), serum Ca/P (AUC = 0.735, P = 0.010) and OC (AUC = 0.729, P = 0.013) had high sensitivity and specificity. CONCLUSION: Preoperative serum P, serum Ca/P and osteocalcin levels may identify patients with PHPT at risk for early postoperative SH after PTX.

Neonatal Calcinosis Cutis After Treatment of Hypocalcemia with Calcium Gluconate: A Report of 2 Cases.

BACKGROUND Calcium gluconate is used to treat neonatal hypocalcemia, severe hyperkalemia, and neonatal convulsions. Calcium gluconate can extravasate into the skin's soft tissues, resulting in redness, skin nodules, and calcification of soft tissue, which can cause tissue necrosis. This report presents 2 cases of neonatal calcinosis cutis following the treatment of hypocalcemia with calcium gluconate. CASE REPORT Case 1. The patient was a 12-day-old male neonate who presented with a mass in the right foot. He was recently discharged from the hospital after evacuation of subdual hematoma triggering his seizures. The swelling was associated with erythema but no discharge. His radiograph showed soft tissue calcification. He had received 2 peripheral intravenous calcium gluconate infusions to manage hypocalcemia during the last hospitalization. Symptomatic treatments were provided, and full resolution of the swelling was reported after 3 weeks. Case 2. The patient was a 1-month-old female infant newly diagnosed with cystic fibrosis who presented with a mass in her left foot. She underwent exploratory laparotomy in another hospital to manage meconium ileus. The mass was not mobile but there was no skin ulceration. Her radiograph showed soft tissue calcification. During her last admission, she had received 3 doses of intravenous calcium gluconate to manage hypocalcemia. The patient was observed and managed symptomatically. After 4 weeks, there was almost complete clinical and radiographic disappearance of the swelling without any skin necrosis. CONCLUSIONS This report has highlighted the importance of monitoring neonates treated with calcium gluconate who may develop skin rashes or nodules due to calcinosis cutis.