Endocrine manifestations in adults with 22q11.2 deletion syndrome: a retrospective single-center cohort study.

INTRODUCTION AND OBJECTIVE: Patients with the 22q11.2 deletion syndrome (22q11DS) frequently display cardiological and psychiatric diseases, but are also at increased risk for endocrine manifestations. The aim of this study was to evaluate the screening, prevalence, and management of hypoparathyroidism and thyroid disease in patients with 22q11DS, to evaluate the metabolic profile, and to compare these results with current literature and guidelines. DESIGN: We performed a retrospective study of patients with genetically confirmed 22q11DS, followed at the center for human genetics of the University Hospitals Leuven, resulting in a cohort of 75 patients. Medical history, medication, and laboratory results concerning hypoparathyroidism, thyroid dysfunction, and the metabolic profile were collected. RESULTS: Of the total cohort, 26 patients (35%) had at least one hypocalcaemic episode. During hypocalcaemia, parathyroid hormone (PTH) was measured in only 12 patients with 11 having normal or low PTH, confirming a diagnosis of hypoparathyroidism. Recurrent episodes of hypocalcaemia occurred in seventeen patients (23%). Adherence to the guidelines was low, with 13% of patients having a yearly serum calcium evaluation, 12% receiving daily calcium supplements, and 20% receiving non-active vitamin D. Hypothyroidism was present in 31 patients (44%) and hyperthyroidism in 6 patients (8%). Information on body mass index (BMI) was available in 52 patients (69%), of which 38% were obese (BMI ≥ 30 kg/m2). CONCLUSION: Hypoparathyroidism, hypothyroidism, and obesity are common endocrine manifestations in patients with 22q11DS but are probably underdiagnosed and undertreated, indicating the need for multidisciplinary follow-up including an endocrinologist.

The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023.

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

Parathyroid Hormone Resistance: An Uncommon Cause of Hypocalcaemia in an Adult Ghanaian Female.

BACKGROUND AND OBJECTIVE: Parathyroid hormone (PTH) resistance, the main biochemical feature of a rare group of disorders known as Pseudohypoparathyroidism (PHP) is an uncommon cause of hypocalcaemia. In addition to the biochemical abnormalities, some individuals with PHP may have features of Albright Hereditary Osteodystrophy (AHO). Being a rare disorder with a significant level of variation and overlap in its clinical presentation, diagnosis of PHP may be challenging in some clinical settings. This case report highlights the diagnosis of this rare disorder. CASE REPORT: A 20-year-old Ghanaian female who had been involved in a road traffic accident (RTA) was referred to the endocrine clinic after a computer tomography (CT) scan of her head revealed an incidental finding of multiple basal ganglia calcifications. Investigations revealed hypocalcaemia, hyperphosphatemia, and elevated intact PTH in the presence of normal levels of 25-hydroxyvitamin D and magnesium, and a normal kidney function. She also had phenotypic features of AHO. Findings suggested a diagnosis of PHP, however, the type could not be identified due to the unavailability of further testing. CONCLUSION: This report of a Ghanaian female with PTH resistance and features of AHO diagnosed at the age of 20 years, is expected to add to the existing literature and assist in increasing the level of awareness and facilitate the diagnosis of this disorder in our setting.

CONTEXTE ET OBJECTIF: La résistance à l'hormone parathyroïdienne (PTH), principale caractéristique biochimique d'un groupe rare de troubles connus sous le nom de pseudohypoparathyroïdie (PHP), est une cause rare d'hypocalcémie. En plus des anomalies biochimiques, certaines personnes atteintes de PHP peuvent présenter des caractéristiques d'ostéodystrophie héréditaire d'Albright (AHO). Étant un trouble rare avec un niveau significatif de variation et de chevauchement dans sa présentation clinique, le diagnostic de PHP peut être difficile dans certains contextes cliniques. Ce rapport de cas met en lumière le diagnostic de cette maladie rare. RAPPORT DE CAS: Une femme ghanéenne de 20 ans qui avait été impliquée dans un accident de la circulation routière (RTA) a été référée à la clinique endocrinienne après qu'une tomodensitométrie (TDM) de sa tête a révélé la découverte fortuite de multiples calcifications des ganglions de la base. Les examens ont révélé une hypocalcémie, une hyperphosphatémie et une PTH intacte élevée en présence de taux normaux de 25 hydroxyvitamine D et de magnésium et d'une fonction rénale normale. Elle avait également des caractéristiques phénotypiques d'AHO. La découverte a suggéré un diagnostic de PHP, mais le type n'a pas pu être identifié en raison de l'indisponibilité de tests supplémentaires. CONCLUSION: Ce rapport d'une femme ghanéenne présentant une résistance à la PTH et des caractéristiques d'AHO diagnostiquée à l'âge de 20 ans, devrait s'ajouter à la littérature existante et aider à accroître le niveau de sensibilisation et à faciliter le diagnostic de ce trouble dans notre contexte. Mots-clés: Hypocalcémie, Hormone parathyroïdienne, Ghana.

Preoperative and postoperative optimisation of patients undergoing thyroid surgery: a multicentre quality improvement project at Barts Health NHS Trust.

Hypocalcaemia following thyroid surgery can occur in up to 38% of patients. With over 7100 thyroid surgeries performed in 2018 in the UK, this is a common postoperative complication. Undertreated hypocalcaemia can result in cardiac arrhythmias and death. Preventing adverse events from hypocalcaemia requires preoperative identification and treatment of at-risk patients with vitamin D deficiency, timely recognition of postoperative hypocalcaemia and prompt appropriate treatment with calcium supplementation. This project aimed to design and implement a perioperative protocol for prevention, detection and management of post-thyroidectomy hypocalcaemia. A retrospective audit of thyroid surgeries (n=67; October 2017 to June 2018) was undertaken to establish baseline practice of (1) preoperative vitamin D levels assessment, (2) postoperative calcium checks and incidence of postoperative hypocalcaemia and (3) management of postoperative hypocalcaemia. A multidisciplinary team approach following quality improvement principles was then used to design a perioperative management protocol with all relevant stakeholders involved. After dissemination and implementation, the above measures were reassessed prospectively (n=23; April-July 2019). The percentage of patients having their preoperative vitamin D measured increased from 40.3% to 65.2%. Postoperative day-of-surgery calcium checks increased from 76.1% to 87.0%. Hypocalcaemia was detected in 26.8% of patients before and 30.43% of patients after protocol implementation. The postoperative component of the protocol was followed in 78.3% of patients. Limitations include low number of patients which precluded from analysis of the impact of the protocol on length of stay. Our protocol provides a foundation for preoperative risk stratification and prevention, early detection and subsequent management of hypocalcaemia in thyroidectomy patients. This aligns with enhanced recovery protocols. Moreover, we offer suggestions for others to build on this quality improvement project with the aim to further advance the perioperative care of thyroidectomy patients.

Serum PTH at 4 h after total thyroidectomy as a predictor of hypocalcemia: a prospective time frame analysis in search of evidence.

INTRODUCTION: There has not been a universal agreement about the timings and the threshold level of PTH that can accurately predict the risk of hypocalcemia. Our study aimed to investigate the changes in the serum PTH levels at various time intervals and correlate it with the development of subsequent hypocalcemia. MATERIALS AND METHODS: All patients had a pre-operative serum PTH done and were again assessed intra-operatively, at 4 h, 24 h, 72 h, and 1 month after the thyroid surgery. Absolute serum PTH value at various time points, absolute change in serum PTH values compared to pre-operative level, and relative change (percentage change) in serum PTH values compared with pre-operative levels were used to predict post-operative Hypocalcemia. RESULTS: 49 patients were included in the study. The sensitivity and negative predictive value was 100% for serum PTH at 4 h. There was a statistically significant difference between the groups that required calcium supplementation versus the group that did not require it. The maximum relative reduction in serum PTH value with respect to the pre-operative level occurred at 4 h in the calcium supplement required group which was 82.5%. Use of combination of 4 h serum PTH and relative change at 4 h yielded the best results. CONCLUSION: A combination of absolute serum PTH level at 4 h and the relative decline in serum PTH at 4 h has the highest diagnostic accuracy. The use of this combined parameter helps to reliably predict patients who would require supplementation.

A case of myopathy and markedly elevated creatine kinase levels with hypocalcemia, hypomagnesemia, and hyposelenemia due to short bowel syndrome after rectal cancer resection.

A 66-year-old Japanese man was referred to our hospital with myalgia and muscle weakness. He had a history of rectal cancer, which invaded into the urinary bladder and ileum and was treated with chemotherapy, radiotherapy, resection of the rectum, colostomy, and ileal conduit construction. He showed recurrent markedly elevated serum creatine kinase levels and concurrent hypocalcemia. Muscle magnetic resonance imaging demonstrated abnormal signals in the proximal limb muscles, and needle electromyography showed myopathic changes. Further examination revealed hypomagnesemia and hyposelenemia with underlying short bowel syndrome. Calcium, magnesium and selenium supplementation improved his symptoms and laboratory findings.

Considerations in the Diagnosis and Treatment of Early Lactation Calcium Disturbances.

This article reviews the history of clinical hypocalcemia and the evolving definition of subclinical hypocalcemia, targeting a concept for consideration that not all hypocalcemia is negative. With a goal of presenting bovine practitioners information to assist with individual animal hypocalcemia diagnosis and treatment as well as herd-level monitoring and prevention, we present current methods of direct calcium measurement, therapeutic interventions for clinical hypocalcemia, and postpartum calcium supplementation options and their efficacy. We encourage veterinarians to understand calcium dynamics in the immediate postpartum period and evaluate how individual cow therapy and herd prevention protocols can assist with supporting calcium regulation.

Postoperative Hypocalcemia in Hyperthyroid Patients: The Parathyroids Aren't Always to Blame.

INTRODUCTION: Hypocalcemia is commonly reported after thyroidectomy and has multiple possible etiologies including: parathyroid devascularization, reactive hypoparathyroidism from relative hypercalcemia in thyrotoxicosis, and abrupt reversal of thyrotoxic osteodystrophy. In patients that are actively hyperthyroid and undergoing thyroidectomy, it is not known how many experience hypocalcemia from nonhypoparathyroidism etiologies. Therefore, our aim was to examine the relationship among thyrotoxicosis, hypocalcemia, and hypoparathyroidism. METHODS: A retrospective review was performed of prospectively-collected data from all patients undergoing thyroidectomy for hyperthyroidism by 4 surgeons from 2016 to 2020. All patients carried a diagnosis of Graves' disease or toxic multinodular goiter. Patient demographics, preoperative medications, laboratory reports, and postoperative medications were reviewed. Hypocalcemia within the first month of surgery despite a normal parathyroid hormone (PTH) level was the primary outcome of interest and was compared between patients with and without thyrotoxicosis. Secondary outcomes were duration of postoperative calcium use and the relationship between preoperative calcium supplementation and postoperative calcium supplementation. Descriptive statistics, Wilcoxon rank-sum, and chi-square tests were used for bivariate analysis, as appropriate. RESULTS: A total of 191 patients were identified, with mean age of 40.5 y (range 6-86). Most patients were female (80%) and had Graves' disease (80%). At the time of surgery, 116 (61%) had uncontrolled hyperthyroidism (thyrotoxic group, Free Thyroxine >1.64 ng/dL or Free Triiodothyronine > 4.4 ng/dL), with the remaining 75 (39%) considered euthyroid. Postoperative hypocalcemia (calcium < 8.4 mg/dL) developed in 27 (14%), while hypoparathyroidism (PTH < 12 pg/mL) was observed in 39 (26%). Thyrotoxic patients comprised a majority of those with hypocalcemia (n = 22, 81%, P = 0.01) and hypoparathyroidism immediately following surgery (n = 14, 77%, P = 0.04). However, a majority of initially hypocalcemic, thyrotoxic patients had normal PTH values within the first month after surgery (n = 17, 85%), pointing to a potential nonparathyroid etiology. On bivariate analysis, no significant relationship was found for thyrotoxic patients with initial postoperative hypocalcemia (18%) and hypoparathyroidism <1-month after surgery (29%, P = 0.29) or between 1 and 6 mo after surgery (2%, P = 0.24). Of the 19 patients in the nonhypoparathyroidism group, 17 (89%) were off all calcium supplements by 6 mo postop. CONCLUSIONS: In patients with hyperthyroidism, those in active thyrotoxicosis at time of surgery have a higher rate of postoperative hypocalcemia compared to euthyroid patients. When hypocalcemia lasts >1 mo postoperatively, data from this study suggest that hypoparathyroidism may not be the primary etiology in many of these patients, who typically require calcium supplementation no more than 6 mo postoperatively.

An Endocrinological Perspective on 22q11.2 Deletion Syndrome: A Single-center Experience

Objective: 22q11.2 deletion syndrome (22q11.2 DS) is the most common chromosomal microdeletion disorder. Associated problems in 22q11.2 DS may include cardiac abnormalities, immune dysfunction, facial dysmorphism, with endocrine, genitourinary and gastrointestinal problems, and developmental delay. The aim of this study was to evaluate and present all endocrinological findings of patients with 22q11.2 DS from a single center. Methods: All participants had confirmed 22q11.2 DS by fluorescence in situ hybridization with hypoparathyroidism. Data were retrieved by retrospective review of patient records. Results: A total of 17 patients were reviewed. On physical examination, all patients had similar dysmorphic features. The median age at diagnosis was 45 days (1 day-13 years). Most cases (64.7%, 11/17) were diagnosed with hypoparathyroidism incidentally after routine tests. At the time of diagnosis, mean calcium was 7.04±0.80 mg/dL, phosphorus was 6.2±1.1 mg/dL, and median parathyroid hormone (PTH) was 11.5 (3.7-47.6) ng/L. Transient hypoparathyroidism was detected in five cases (29.4%). There was no significant difference between patients with permanent or transient hypoparathyroidism regarding gender, age at diagnosis, calcium, phosphorus, and PTH levels. However, vitamin D levels were significantly lower in the transient group (p=0.036). During follow-up, short stature, obesity, and type 2 diabetes mellitus were absent. Thyroid autoantibodies were detected in two patients with normal thyroid function tests. Despite there being no pathological short stature, final stature was shorter than the general population (mean height standard deviation score: -0.94±0.83). Conclusion: Hypocalcemia may be detected during acute illness in some cases where hypocalcemia appears at later ages. There was no significant difference between permanent and transient hypoparathyroidism cases in terms of PTH level. Recognition of the more specific facial findings is important to trigger investigation of genetic variants, additional anomalies, and for follow-up.

Accuracy of Serum Parathyroid Hormone Measured on the Early Morning of the First Postoperative Day in Predicting Clinically Significant Post-Total Thyroidectomy Hypocalcemia.

INTRODUCTION: Clinical hypocalcemia (CH) following total thyroidectomy (TT) is a potentially life-threatening condition if left untreated. This study aimed at evaluating the accuracy of parathyroid hormone (PTH) measured in the early morning of the first postoperative day (POD-1) in predicting CH, and determining the cutoff values of PTH that can predict the development of CH. METHODS: We performed a retrospective review of patients undergoing TT between February 2018 and July 2022. Serum PTH, calcium, and albumin levels were measured on morning (6-8 AM) of postoperative day one (POD-1), and serum calcium level was measured from POD-2 onwards. We performed ROC curve analysis to determine the accuracy of PTH in predicting postoperative CH, and cutoff values of PTH to predict CH. RESULTS: Ninety-one patients, 52 (57.1%) with benign and 39 (42.9%) with malignant goiter were included. The incidence of biochemical, and clinical hypocalcemia was 24.2% and 30.8%, respectively. In our study serum, PTH measured in the early morning of first postoperative day following TT was found to have good accuracy (AUC = .88) in predicting CH. A PTH value of ≥27.15 pg/mL was found to have a 96.4% sensitivity in ruling out CH, while a serum PTH value <10.65 pg/mL had a specificity of 95.2% in predicting CH. DISCUSSION: Patients with a serum PTH value of ≥27.15 pg/mL can be discharged without any supplements, those with PTH <10.65 pg/mL should be started on calcium and calcitriol supplements, while patients having PTH values between 10.65 and 27.15 pg/mL should be monitored for the development of signs and/or symptoms of hypocalcemia.

Intestinal hypomagnesemia in an Iranian patient with a novel TRPM6 variant: a case report and review of the literature.

TRPM6 is predominantly expressed in the kidney and colon and encodes a protein containing an ion channel domain and a protein kinase domain. It is crucial for magnesium homeostasis and plays important roles in epithelial magnesium transport and the active magnesium absorption. In this study, we present a 70-day-old Iranian female patient from consanguineous parents with hypomagnesemia and secondary hypocalcemia. She presented with seizures 19 days after birth and refractory watery non-bloody diarrhea. She consequently had failure to thrive. Other features included hypotonia, wide anterior fontanel, ventriculomegaly, and pseudotumor cerebri following administration of nalidixic acid. She had severe hypomagnesemia and hypocalcemia which were treated with magnesium and calcium supplementation. Despite initial unstable response to supplemental magnesium, she eventually improved and the diarrhea discontinued. The patient was discharged by magnesium and calcium therapy. At the last follow-up at age 2.5 years, the patient remained well without any recurrence or complication. Genetic testing by whole-exome sequencing revealed a novel homozygous frameshift insertion-deletion (indel) variant in exon 26 of the TRPM6 gene, c.3693-3699del GCAAGAG ins CTGCTGTTGACATCTGCT, p.L1231Ffs*36. Segregation analysis revealed the TRPM6 heterozygous variant in both parents. Patients with biallelic TRPM6 pathogenic variants typically exhibit hypomagnesemia with secondary hypocalcemia and present with neurologic manifestations including seizures. In some patients, this is also complicated by chronic diarrhea and failure to thrive. Long-term complications are rare and most of the patients show a good prognosis with supplemental magnesium therapy.

Predictive value of 6 h postoperative parathyroid hormone level on permanent hypoparathyroidism in pediatric total thyroidectomy: a pilot study.

OBJECTIVES: Transient hypocalcemia is a common complication after pediatric total thyroidectomy, while permanent hypoparathyroidism (PH) is relatively uncommon. To date there is no model to predict which patients will develop PH based on post-operative makers. We aim to identify pediatric patients who are at high risk of PH following thyroidectomy based on 6 h post-operative parathyroid hormone (PTH) value. METHODS: A retrospective review of 122 pediatric patients undergoing total thyroidectomy between 2016 and 2022 following implementation of a multidisciplinary team was performed. Outcome of interest was permanent hypoparathyroidism, defined as need for calcium supplementation at 6 months postoperatively. Receiver operating characteristic (ROC) analysis was used to determine PTH value at 6 h post-operative that was predictive of permanent hypoparathyroidism. RESULTS: Rates of permanent hypoparathyroidism reported are similar to those described in the literature with 12 patients (10.9%) developing PH. In patients who developed PH, mean 6 h postoperative PTH was 5.12 pg/mL. Mean 6 h postoperative PTH level in those who did not develop PH was 31.34 pg/mL (p<0.0001). The 6 h post-operative PTH value predictive for PH was ≤11.3 pg/mL. PTH cutoff of ≤11.3 pg/mL had a sensitivity of 100%, specificity of 72.2%, positive predictive value (PPV) of 27.0%, and negative predictive value (NPV) of 100%. CONCLUSIONS: 6 h postoperative PTH values were found to be predictive of permanent hypoparathyroidism in pediatric total thyroidectomy: a 6 h postoperative PTH level of >11.3 pg/mL excludes permanent hypoparathyroidism, but if PTH is ≤11.3 pg/mL at 6 h, approximately 1/3 of patients may persist with permanent hypoparathyroidism.

Hypocalcemia after parathyroidectomy in patients with a history of bariatric surgery.

PURPOSE: A growing body of literature has suggested that a history of bariatric surgery increases the risk of hypocalcemia after subsequent thyroidectomy, however little is known about the risk after parathyroidectomy. The purpose of this study was to determine the incidence of hypocalcemia after parathyroidectomy in patients with prior bariatric surgery. METHODS: The TriNetX Research Network was queried using diagnosis and procedure codes to identify patients with a history of bariatric surgery who were subsequently diagnosed with primary hyperparathyroidism (PHP) and underwent parathyroidectomy between 2012 and 2022. The rate of hypocalcemia after parathyroidectomy was compared between those with a history of bariatric surgery and controls who underwent parathyroidectomy alone, matched for demographics, body mass index (BMI) ≥ 30 kg/m2, and history of calcium or vitamin D supplementation. RESULTS: There were 34,483 included patients diagnosed with PHP who underwent parathyroidectomy. Of this cohort, 1.4% (n = 472) had prior bariatric surgery. There were 90% females and 10% males in this subset of patients, and the average age was 58 years. Compared to matched controls who underwent parathyroidectomy alone, these patients had a significantly increased risk of hypocalcemia within 0-1 month (RR, 95% CI, P) (17.2% vs. 9.3%; 1.8, 1.3-2.6, P < 0.001), 1-6 months (8.5% vs. 2.5%; 3.3, 1.8-6.3, P < 0.001) and 6-12 months (6.8% vs. 2.3%; 2.9, 1.5-5.7, P < 0.001) following surgery. CONCLUSION: The current study is the first to indicate that patients with a history of bariatric surgery are at increased risk for short-term and permanent hypocalcemia after parathyroidectomy. Further research is required to determine optimal prevention and treatment strategies to decrease associated morbidity in this subset of patients.

Predictive value of postoperative day 1 parathyroid hormone levels for early and late hypocalcaemia after thyroidectomy.

PURPOSE: Early parathyroid hormone (PTH) levels after total thyroidectomy can predict patients at low risk of hypocalcaemia who can be discharged early without calcium supplementation. For centres without facility to perform early PTH levels, PTH levels sent on the first postoperative day (POD1) may be an alternative. However, there is less data regarding optimal cut-off PTH levels for POD1 discharge. METHODS: Retrospective review of prospective database of thyroid operations between September 2009 and February 2020 at tertiary referral centre. Main outcome measure was symptomatic hypocalcaemia. RESULTS: Five hundred seventy patients undergoing total (521) or completion thyroidectomy with POD1 PTH levels available were included. Among patients with POD1 PTH levels ≥ 20 pg/ml and POD1 calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia was 1% (3/300), and need for intravenous calcium 0.3% (1/300). For POD1 PTH levels 15-19 pg/ml and POD1 calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia and need for intravenous calcium was 5.4% (3/55). For PTH levels 10-14 pg/ml and calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia and need for intravenous calcium was 11.7% (7/60). The risk of permanent hypoparathyroidism was < 1% for POD1 PTH levels ≥ 15 pg/ml; 5.4% for levels 10-14 pg/ml; and 19.8% for levels < 10 pg/ml. CONCLUSIONS: POD1 PTH levels ≥ 15 pg/ml along with calcium ≥ 2.0 mmol/l are associated with low risk of symptomatic hypocalcaemia, and represent a safe criterion for discharge of most patients without calcium supplementation. For certain patient groups, a higher threshold of 20 pg/ml could be considered.

Hipocalcemia, hipomagnesemia y uso crónico de inhibidores de la bomba de protones / Hypocalcemia, hypomagnesemia, and chronic use of proton pump inhibitors

Introducción: Los inhibidores de la bomba de protones son fármacos usados en múltiples gastropatías. El omeprazol pertenece a este grupo de medicamentos y es aprobado y catalogado como indispensable por la Organización Mundial de la Salud. Esto ha causado que su uso se vuelva constante y hasta cierto punto equívoco. Pese a ser medicamentos seguros muestran efectos secundarios, dentro de los cuales uno ocasional es el trastorno hidroelectrolítico. Objetivo: Presentar un caso clínico en el cual se constató la presencia de efectos secundarios tras el uso de un fármaco de uso constante por la comunidad médica: el omeprazol. Caso clínico: Se presenta a continuación el caso clínico de un paciente masculino con antecedente de hipertensión arterial y gastropatía crónica que muestra uso por 8 años consecutivos de inhibidores de la bomba de protones, al cual se le diagnostica hipomagnesemia e hipocalcemia. Se obtuvieron resultados de laboratorio normales tras administración de suplementos orales y uso de ranitidina con supresión de terapéutica con omeprazol. Conclusiones: Un control constante de los fármacos que usan los pacientes crónicos es fundamental en atención primaria de salud. El uso de inhibidores de la bomba de protones se ha convertido en rutinario y es necesario corroborar siempre la dosis y el tiempo de uso de los fármacos además de la relación con otros medicamentos que use el paciente(AU)

Introduction: Proton-pump inhibitors are drugs used in multiple gastropathies. Omeprazole belongs to this group of medicines; it is approved and classified as essential by the World Health Organization. This has permitted for its use to become constant and, to some extent, misleading. Despite being safe drugs, they show side effects, among which an occasional one is fluid and electrolyte disorders. Objective: To present a clinical case in which the occurrence of side effects was verified after the administration of a drug constantly used by the medical community. Clinical case: The following is a clinical case of a male patient with a history of arterial hypertension and chronic gastropathy, characterized by the usage of proton-pump inhibitors for eight consecutive years, diagnosed with hypomagnesemia and hypocalcemia. Normal laboratory results were obtained after oral supplementation and usage of ranitidine with suppression of omeprazole therapy. Conclusions: Constant control of the drugs used by chronic patients is essential in primary health care. The usage of proton-pump inhibitors has become a routine. It is always necessary to check the dose and time for using the drugs as well as the relationship with other drugs used by the patient(AU)

Late diagnosis of chronic hypocalcemia due to autoimmune hypoparathyroidism.

Hypoparathyroidism is most often the result of postsurgical damage to the parathyroid glands but may occasionally be autoimmune hypoparathyroidism. In the latter context, activating antibodies directed against the calcium-sensing receptor (CaSR) have been described. We hereby present the case of a patient suffering from chronic recurrent muscle cramps and paresthesia, presenting for a seizure due to hypocalcaemia. After eliminating the possibility of a genetic disorder, we searched for autoimmune hypoparathyroidism as there was no obvious cause of hypoparathyroidism. The search for anti-CaSR antibodies was positive. There was no argument for autoimmune polyendocrine syndrome type 1 so we concluded that it was isolated autoimmune hypoparathyroidism caused by activating antibodies to the CaSR. The patient was treated with vitamin D and calcium supplementation. The search for complications of hypoparathyroidism and hypercalciuria revealed basal ganglia calcification. The patient's hypocalcaemia is now being kept under control with oral supplementation.

Identification of secondary predictive factors for acute hypocalcemia following thyroidectomy in patients with low postoperative parathyroid hormone levels without overt calcium deficiency: A cohort study.

BACKGROUND: The transient acute hypocalcemia (HypoCa) is the most prevalent complication after total thyroidectomy, detected primarily by subnormal intact parathyroid hormone (iPTH) and calcium levels. However, the need for calcium supplementation is ambiguous in patients who exhibit low iPTH with normal calcium levels. The aim of this study was to evaluate complementary predictors of HypoCa in this scenario. METHODS: A retrospective cohort study with of 1597 consecutive patients undergoing total thyroidectomy, with or without neck dissection, from January 2014 to December 2018 at a single institution. Patients with an iPTH <12 pg/mL and a total calcium level ≥8 mg/dL in the first 8 h after surgery were included. RESULTS: 1597 patients identified with low postoperative iPTH without overt calcium deficiency was diagnosed. The transient HypoCa in that specific subgroup was 509 (31.9%). Multivariate analysis indicated that HYPOCA was associated with bilateral level VI neck dissection and pre- to postoperative calcium reduction >38 pg/mL. To better illustrate the model, we plotted a nomogram with the variables selected for the final model. CONCLUSION: Total thyroidectomy patients who exhibit low postoperative iPTH levels without overt calcium deficiency should be considered for calcium replacement therapy when they a marked drop in iPTH postoperatively and underwent bilateral level VI neck dissection.

Hungry Bone Syndrome After Living Donor Liver Transplant for Biliary Atresia.

Hungry bone syndrome is a rare but potentially lethal complication that is characterized by rapid, severe, long-lasting hypocalcemia and hypophosphatemia secondary to increased bone metabolism. We present a case of hungry bone syndrome after living donor liver transplant for biliary atresia. Following a failed Kasai procedure for biliary atresia, a 5-month-old boy underwent living donor liver transplant with reduced left lateral lobe from his father. Despite the oral administration of alfacalcidol, the patient exhibited severe craniotabes before the surgery. He developed severe hypocalcemia and hypophosphatemia im-mediately after liver transplant and required supplementation of calcium and phosphorus for 1 month thereafter. After serum levels of calcium and phosphate had normalized, there was a rapid increase in the serum bone-type alkaline phosphatase level, and the craniotabes subsided remarkably. To our knowledge, this is the world's first reported case of hungry bone syndrome after liver transplant for cholestatic cirrhosis. It underscores the importance of strict nutritional and electrolyte management in the perioperative period. A prompt diagnosis and correction of hungry bone syndrome are imperative to prevent the associated significant morbidity and mortality.

Type-5 Bartter syndrome presenting with metabolic seizure in adulthood.

Bartter syndrome is a very rare and heterogeneous disease with variable age of onset and symptom severity. Genotypically they have inherited disorders of the thick ascending limb in the renal tubular system, which manifest phenotypically as electrolyte imbalance due to loss of sodium, chloride and potassium. Gain of function mutations in the calcium-sensing receptor has been described in some patients with Bartter's syndrome (type-5 Bartter syndrome or autosomal dominant hypocalcaemia with Bartter syndrome) associated with hypocalcaemia and hypercalciuria differentiating it from Gitelman syndrome. This phenotype has been reported to present in adulthood with metabolic abnormalities. We present a case of a middle-aged woman who presented with metabolic seizures and on evaluation was found to have profound electrolyte abnormalities which were corrected with supplements and led to the resolution of symptoms.