Iatrogenic calcinosis cutis in 9-month-old baby boy: a case report.

BACKGROUND: Calcinosis cutis is a rare condition, characterized by an accumulation of calcium salts in the skin and subcutaneous tissue. There are several types of this condition, including dystrophic, metastatic, idiopathic, calciphylaxis, and iatrogenic calcinosis cutis. The type related to our case is iatrogenic calcinosis cutis, and one its possible causes is calcium intravenous infusion. Physicians should be aware of this condition when giving calcium infusion. CASE PRESENTATION: Here we report the case of a 9-month-old Arabic - Saudi baby boy, who presented with abnormal movement for 1 day. Upon further investigation, his abnormal movement was found to be a manifestation of hypocalcemia and vitamin D deficiency. He was treated with intravenous calcium gluconate. Later, he had a treatment-related complication of intravenous calcium at the site of venipuncture causing swelling, which was initially soft but progressed to hard, over the left hand. Eventually, he was diagnosed with a case of iatrogenic calcinosis cutis due to intravenous calcium treatment. CONCLUSION: There are multiple differential diagnoses of calcinosis cutis, as it resembles many other conditions. Careful history-taking, physical examination, and other investigations, such as radiological investigations, will aid in reaching a more accurate diagnosis and, thus, early treatment and intervention. Frequently checking the intravenous line and diluting the intravenous calcium may help reduce the occurrence of iatrogenic calcinosis cutis.

Resolution of Left Bundle Branch Block After Calcium Administration in the Prehospital Setting.

Hyperkalemia is a medical emergency with potentially severe consequences that can be avoided by early recognition and effective treatment. Electrocardiogram (ECG) changes can help elucidate hyperkalemia prior to obtaining lab results and assist in early decisions on treatment, especially in the prehospital setting. ECG changes commonly associated with hyperkalemia are peaked T-waves, PR prolongation, P-wave flattening, QRS widening, or a sine-wave pattern at severely elevated potassium levels. Bundle branch blocks (BBBs) are associated with hyperkalemia but are less common and less well known in this setting. We report a case of a prehospital ECG showing a left bundle branch block (LBBB) in a patient who had end-stage renal disease, and the prehospital treatment with calcium chloride lead to resolution of the LBBB. The patient was eventually found to have a serum potassium level of 6.1 mEq/L.

Comparison of different calcium supplementation methods in patients with osteoporosis.

The aim of the present study was to explore the clinical efficacy and safety of different methods of calcium supplementation in osteoporosis (OP). Patients with OP were divided into four groups, including the control, oral calcium supplementation, intravenous calcium supplementation and combined calcium supplementation groups. The duration of the calcium supplementation was 3-6 years. Medical records were collected and examined along with demographic data, the incidence of certain diseases and adverse reactions. All subjects in the three treatment groups exhibited statistically significant reductions in alkaline phosphatase (ALP) levels, visual analog score (VAS) and Oswestry Disability Index (ODI) compared with the respective pre-treatment values. Furthermore, compared with prior to treatment, the lumbar and hip bone mineral density (BMD) of patients receiving intravenous calcium supplementation was significantly increased. In addition, after treatment, the lumbar and hip BMD was significantly increased, whereas ALP levels, VAS and ODI were significantly decreased in the oral calcium supplementation group compared with the control group. Also, compared with the control and oral calcium supplementation groups, the BMD was significantly increased, whereas ALP, VAS, ODI, the rate of infection and tooth loss, the incidence of fragility fractures, joint replacement surgery, arrhythmia, lumbar disc herniation and cerebral infarction were significantly decreased in the two groups treated with intravenous calcium supplementation. The results of the present study may enable a better understanding of the effectiveness and safety of the different methods for supplementing calcium in OP.

Hypocalcemia in an 11 Year Old Child: A Difficult Case to Treat.

Hypocalcemia is a laboratory and clinical abnormality that is observed especially in neonates and paediatric patients. Laboratory hypocalcaemia is often asymptomatic but it can manifest as central nervous system irritability, paraesthesia, tetany (i.e. contraction of hands, arms, feet, larynx, bronchioles), seizures, and even psychiatric changes in children. Cardiac function may also be impaired because of poor muscle contractility. We report a unique case of an eleven year old male child who presented with chronic kidney disease associated with severe hypocalcemia, tonic-clonic seizures, hypovitaminosis D but normal electroencephalogram and electrocardiography. The child required prolonged intravenous calcium gluconate therapy to correct his ionised calcium levels.

Regional citrate anticoagulation with calcium replacement in pediatric apheresis.

PURPOSE: The objective of this retrospective analysis was to present our single-center experience with intravenous (IV) calcium replacement and regional citrate anticoagulation in pediatric apheresis therapy with the aim of developing a standard operating procedure to minimize symptomatic hypocalcemia. METHODS: We analyzed apheresis procedures in patients <18 years of age over a 2-year time period (Jan 2012 to Dec 2014). Procedures in tandem with other extracorporeal therapies, including continuous renal replacement therapy, extracorporeal liver support, and extracorporeal membrane oxygenation, were excluded. RESULTS: Two-hundred and six patients underwent 1176 procedures. All procedures were performed with acid citrate dextrose formula A (ACD-A) for anticoagulation and IV calcium replacement. The majority of procedures (56.7%) were therapeutic plasma exchange (TPE). The average rate of IV calcium chloride (2.16 mg/mL of elemental calcium) was 60.4 ± 21.4 mL/h while inlet flow rate was 43.7 ± 16.3 mL/min. Patients experienced hypocalcemia in 63 of 1176 procedures (5.3%), including 48 episodes (4.1%) of hypocalcemia during apheresis treatment. Two procedures with hypocalcemia had symptoms: one slight lip twitch and one patient with abdominal pain. No hemodynamic alterations were noted in any procedure associated with hypocalcemia. Hypocalcemia was seen the least with RCE. For patients with hypocalcemia prior to the apheresis session, we used a calcium infusion running at 1.6 times the inlet flow rate. CONCLUSION: Running IV calcium at 1.4 times the inlet flow rate resulted in a lower incidence of hypocalcemia than reported in literature describing other approaches to apheresis. It nearly eliminated episodes of symptomatic hypocalcemia.

Management of hyperkalaemia.

Hyperkalaemia, an elevated extracellular fluid potassium concentration, is a common electrolyte disorder and is present in 1-10% of hospitalised patients. Elevated serum potassium concentrations are usually asymptomatic but may be associated with electrocardiogram (ECG) changes. Hyperkalaemia occasionally leads to life-threatening cardiac arrhythmias. Prompt recognition of this disorder, patient risk management and administration of appropriate treatment can prevent serious cardiac complications of hyperkalaemia. Further assessment of the underlying basis for hyperkalaemia usually reveals a problem with renal potassium excretion (rather than transcellular shift of potassium or excess potassium intake). Reduced potassium excretion is typically associated with decreased potassium secretion in the aldosterone-sensitive distal nephron of the kidney. Common causes for hyperkalaemia include kidney failure, limited delivery of sodium and water to the distal nephron and drugs that inhibit the renin-angiotensin-aldosterone system. Treatment of life-threatening hyperkalaemia (particularly those patients with ECG changes) involves administration of intravenous calcium salts to stabilise the resting cardiac membrane potential. The potassium concentration can be lowered by administration of intravenous insulin combined with an infusion of glucose to stimulate intracellular uptake of potassium. Nebulised ß-2 adrenoceptor agonists can augment the effects of intravenous insulin and glucose pending more definitive management of the recurrent hyperkalaemia risk. Additional management steps include stopping further potassium intake and careful review of prescribed drugs that may be adversely affecting potassium homeostasis. Changes to prescribing systems and an agreed institutional protocol for management of hyperkalaemia can improve patient safety for this frequently encountered electrolyte disorder.