an unusual case of tetany
Post on 11-May-2015
2.194 Views
Preview:
TRANSCRIPT
An unusual ca(u)se of tetany
Prof. S.SUNDAR’s unit,Dr. N.ARUN KUMAR, PG
Case presentation
Chitra 42/f – home-makerAdmitted with the c/o tonic contractions of both the ULs -10 days
h/o presenting illness
Pt was apparently normal till 1 year backc/o tonic contractions of both ULs
-around 10 episodes over past 1 yearIncreased frequency –for past 10 daysAfter developing each episodes –taken parenteral
drug in private hospital & got relieved of the symptom
No investigations done h/o generalized weakness & easy fatiguability
• Not associated with LOC• No h/o tonic clonic movement• No h/o tongue bite• No h/o aspiration• No h/o bladder / bowel incontinence• No h/o aura• No h/o fever• No h/o abdominal pain
Past history
Not a k/c of HTN/DM/CVA/CAD/seizures/PTNot a k/c of hypo/hyperthyroidismNo h/o major surgeryNo h/o chronic drug intakeNo h/o neck irradiation
Personal history• Mixed diet intaker• Normal regular menstrual cycles
Family history• No relevant family history
General examination
• Conscious, oriented, afebrile• No pallor/cyanosis/icterus/clubbing/PE/GLA
Vitals: PR-84/min; BP- 110/80 mmHg; RR-18/min; temp- 36.4
Systemic examination
• CVS- S1, S2 heard, no murmur• RS- NVBS +, no added sounds• Abdomen- soft; no organomegaly• CNS- NFND
Provisional diagnosis
TETANY FOR EVALUATION
Investigations CBC Values
HbTCDCESRRBCHCTPlatelet MCVMCHMCHC
11.8 gm%11000 cells/cummP51, L38, E6, M4, B14/104.4 million34.9%4.84 lakh79.3 fl26.8 pg33.8 gm/dl
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
ABG
• pH 7.486• HCO3 30.9• pCO2 41.8• K 1.26 mmol/L
• Metabolic alkalosis
• 24 hour urine Ca 46.2 mg (N – 100-321mg)• 24 hour urine Cl 323 meq (N – 110-250meq)
• RBS 77 mg%• Blood urea 22 mg%• Serum creatinine 1.0 mg%
• ECG – prolonged Q-T interval
DIAGNOSIS
GITELMAN’S SYNDROME
Gitelman’s syndrome
• Autosomal recessive condition also characterized by hypokalemic metabolic alkalosis, but with hypocalciuria & hypomagnesemia
Pathogenesis of Gitelman’s syndrome
Inactivating mutations in the gene
downregulation
Hypocalciuria Due to associated Plasma volumecontraction
Clinical features
Gitelman’s syndrome is mostly a disorder of adults
Laboratory evaluation
Treatment
• Magnesium aspartate (5-15 mmol Mg/day)• Magnesium oxide • Potassium supplements
Causes of hypocalcemiaLow PTH levels High PTH levelsParathyroid 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)
Causes of hypocalcemiaAssociated 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
Clinical features
Symptoms of hypocalcemia depend on
RAPIDITY
SEVERITY
• Fatigue & muscular weakness• Increased irritability• Loss of memory• Confusion, hallucination, paranoia, depression• ECG manifestation of prolonged Q-T interval
Trousseau’s sign: carpal spasm induced by inflation of BP cuff to >20 mmHg of systolic BP for 3 min
Chvostek’s sign: tapping of facial nerve branches twitching of facial muscles)
Acute hypocalcemia
paraesthesias of the lips &
extremities
muscle cramps
tetany
laryngeal stridor convulsions
Chronic hypocalcemia
cataractsbrittle nails
with transverse
grooves
dry skin
decreased or even absent
axillary & pubic hair
Diagnostic approach to hypocalcemia
• Mesurement of serum Ca
• Measurement of serum PO4, Mg
Diagnostic approach to hypocalcemia
Treatment of hypocalcemia
Depends onRAPIDITY
SEVERITY
ACCOMPANYING COMLICATIONS
Treatment of acute symptomatic hypocalcemia
– Promptly correct symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany with parenteral administration of calcium salts. 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.
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.
Treatment of acute symptomatic hypocalcemia
(contd…)
Patients with cardiac arrhythmias or patients on digoxin therapy need continuous ECG monitoring during calcium replacement because calcium potentiates digitalis toxicity.
Identify and treat the cause of hypocalcemia and taper the infusion.
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.
Treatment of chronic hypocalcemia:Treatment in PTH deficiency
Patients with hypoparathyroidism and pseudo-hypoparathyroidism can be managed initially with the oral administration of calcium supplements.
The hypercalcemic effects of thiazide diuretics may offer some additional benefits.
In patients with severe hypoparathyroidism, vitamin D treatment may be required; however, remember that PTH deficiency impairs the conversion of vitamin D to calcitriol.
Therefore, the most efficient treatment is the addition of 0.5-2 mcg of calcitriol or 1-alpha-hydroxyvitamin D3.
Treatment of chronic hypocalcemia(contd…)
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. 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. Calcitriol may be used, but it has the disadvantages of a higher price and the possibility of producing hypervitaminosis D with hypercalcemia.
Goal of treatmentTo bring serum calcium to low normal range
To avoid hypercalciuria
To avoid nephrolithiasis
top related