Hypocalcaemic tetany linked to vitamin D deficiency and hypomagnesemia in primary intestinal lymphangiectasia: a literature review.

Primary intestinal lymphangiectasia (PIL) is a rare disorder in children causing protein-losing enteropathy. Vitamin D deficiency and hypomagnesemia contributed to the tetany. The literature review reflects the importance of screening for these deficiencies and regular serum magnesium monitoring in PIL cases with neuromuscular or ionic abnormalities.

[Neurological manifestations of hypoparathyroidism: diagnostic difficulties. Case report].

Hypoparathyroidism is a rare condition characterized by reduced production of parathyroid hormone or tissue resistance which leads to hypocalcemia and hyperphosphatemia. Neurological manifestations often occur as the first symptoms of hypoparathyroidism and are characterized by a wide variety of symptoms of both the central and peripheral nervous systems dysfunction, which requires a differential diagnosis with a wide range of neurological diseases. Two clinical cases illustrating the features of subacute and chronic hypoparathyroidism are presented. In the case of subacute hypoparathyroidism, a young woman presented with severe tetany involving the oculomotor muscles (paroxysmal strabismus), laryngeal muscles (respiratory stridor), body muscles (opisthotonus, «obstetrician's hand¼) and the development of secondary myopathy. In another case with a long-term chronic course of postoperative hypoparathyroidism, the patient's adaptation to severe hypocalcemia was noted; the clinical features were dominated by cerebral syndromes due to brain structures calcification (Fahr's syndrome). Possible reasons for late diagnosis of hypoparathyroidism, the importance of active detection of symptoms of neuromuscular hyperexcitability and laboratory testing of phosphorus and calcium metabolism are discussed.

Severe Hypocalcemia as an Atypical Manifestation of Seronegative Celiac Disease in a Patient with Systemic Lupus Erythematosus: Case Report

Aim: To describe the clinical picture and diagnosis of an episode of severe hypocalcemia in a patient with systemic lupus erythematosus (SLE) in remission, with chronic diarrhea that led to the diagnosis of celiac disease (CD). Case presentation: 22-year-old patient, diagnosed with SLE at age 10, in remission. He consulted for a two-month history of paresthesias, muscle spasms, myalgias, and episodes of tetany in the previous week, associated with malabsorptive postprandial diarrhea. His laboratory tests showed severe hypocalcemia, vitamin D deficiency, severe hypomagnesemia, and mild hypokalemia. In the study for CD, serology reported normal anti-tissue transglutaminase IgA, antigliadin IgA, and IgG and low total IgA levels. Enteroscopy revealed erosive bulbo-duodenitis, with villous atrophy and increased intraepithelial lymphocytes in the pathology, which, together with the immunohistochemical study, allowed the diagnosis of CD, Marsh 3a type. Management was initiated with a gluten-free diet, with a positive clinical response. Conclusion: CD should be suspected in patients with SLE who present with diarrhea, abdominal pain, nausea/vomiting, recurrent oral aphthosis, and anemia. In rare seronegative CD cases, other causes of villous atrophy, mainly infectious, toxic, and immunological, must be ruled out. There is an association between CD and SLE, so diagnosis must be early and timely with the best testing scheme available to achieve effective treatment before complications occur.

Objetivo: Describir la presentación clínica y diagnóstico de un episodio de hipocalcemia grave en un paciente con lupus eritematoso sistémico (LES) en remisión, con diarrea crónica que condujo al diagnóstico de enfermedad celíaca (EC). Presentación del caso: Paciente de 22 años, con diagnóstico de LES a los 10 años, en remisión. Consultó por 2 meses de evolución de parestesias, espasmos musculares, mialgias y episodios de tetania en la semana previa, asociado a diarrea posprandial malabsortiva. Sus laboratorios mostraron hipocalcemia grave, déficit de vitamina D, hipomagnesemia grave e hipopotasemia leve. En el estudio para EC la serología reportó antitransglutaminasa tisular IgA, antigliadina IgA e IgG normales y niveles de IgA total bajos. La enteroscopia evidenció bulboduodenitis erosiva, con atrofia de las vellosidades y aumento de linfocitos intraepiteliales en la patología, que junto al estudio inmunohistoquímico permitieron concluir el diagnóstico de EC, tipo Marsh 3a. Se inició el manejo con una dieta libre de gluten, con una respuesta clínica positiva. Conclusión: La EC debe sospecharse en pacientes con LES que inicien con diarrea, dolor abdominal, náuseas/vómitos, aftosis oral recurrente y anemia. En los casos de EC seronegativa, los cuales son poco comunes, se deben descartar otras causas de atrofia de las vellosidades principalmente infecciosas, tóxicas e inmunitarias. Existe una asociación entre EC y LES, por lo cual el diagnóstico debe ser precoz y oportuno con el mejor esquema de pruebas disponible para lograr realizar un tratamiento efectivo antes de que se presenten las complicaciones.

Tetany in a Young Female Not Resulting From Hypocalcemia.

Here, we report on a case of a 24-year-old female who is previously medically healthy. She was admitted with a case of gastroenteritis. During her hospitalization, we noticed that the patient's wrists and metacarpophalangeal (MCP) joints were flexed, with her bilateral proximal (PIP) and distal (DIP) interphalangeal joints extended. Furthermore, she exhibited positive Chvostek and Trousseau signs. Her clinical features were consistent with acute tetany; however, she was demonstrating normal levels of calcium. Other laboratory results were positive for severe metabolic alkalosis and hypophosphatemia. Her signs and symptoms resolved completely after one dose of intravenous calcium gluconate. This case is notable because tetany alongside normocalcemia is a rare condition. Therefore, the immediate management of such cases is crucial.

Hypocalcemic cataract secondary to idiopathic hypoparathyroidism in an adolescent.

Idiopathic hypoparathyroidism is a rare endocrine disorder characterized by hypocalcemia secondary to inadequate parathyroid hormone secretion. Hypocalcemia-related cataract is most often observed in patients with postoperative hypoparathyroidism, whereas primary hypoparathyroidism-related cataract is rare and displays slow progression. Cataract usually occurs in people aged 18 to 50 years. Here, we describe a 17-year-old boy with bilateral cataract and a history of hypocalcemic tetany who was diagnosed with idiopathic hypoparathyroidism. Phacoemulsification with implantation of a monofocal aspherical intraocular lens was performed in the right eye; 6 months later, it was performed in the left eye. Elevated phosphorus and diminished calcium were observed in blood and aqueous humor. A deep anterior chamber, relatively thin central corneal thickness, large white-to-white distance, and thin lens were also observed. During follow-up, neither eye displayed intraocular lens decentration; best-corrected visual acuity was 20/20 in both eyes. These findings suggest that ophthalmologists should be vigilant when hypocalcemic tetany and cataract are present, especially in adolescents and young adults.

Hypocalcemic tetany associated with simultaneous administration of cimetidine and nifedipine: a case report.

BACKGROUND: Acute hypocalcemia is generally caused by a sudden drop in serum calcium ion and presents with a mild or severe form of tetany. Even though the occurrence of hypocalcemia is well documented with certain drugs such as calcium chelators, bisphosphonates, and cisplatin, it is a very unusual and poorly documented adverse event with cimetidine and nifedipine. Here, we present a case of severe hypocalcemic tetany during simultaneous administration of cimetidine and nifedipine in a hypertensive patient with dyspepsia. CASE PRESENTATION: A 46-year-old known human immunodeficiency virus patient from Ethiopia on antiretroviral therapy over the past 14 years presented to the emergency department with acute exacerbation of dyspepsia and hypertensive urgency. She was given intravenous cimetidine (400 mg) and oral nifedipine (30 mg) simultaneously. One hour after the administration of these two drugs, she developed severe hypocalcemic tetany with carpopedal spasm, involuntary plantar flexion, and muscle spasms. She also had severe retrosternal chest pain and shortness of breath. Her blood pressure was 160/110 mmHg during the attack and she had no skin changes, such as urticaria. She was immediately given 1 g of calcium gluconate intravenously over 30 minutes. The carpopedal spasm progressively decreased during calcium gluconate administration. An hour later, she completely regained voluntary movement of her fingers and feet. The chest pain persisted, but resolved over the next 12 hours. The patient was discharged home after 2 days of observation. This is an unusual adverse effect that needs caution during concomitant administration of these drugs. CONCLUSIONS: Severe hypocalcemic tetany can occur with concomitant administration of cimetidine and nifedipine. Immediate treatment with calcium gluconate quickly reverses this adverse event. Concomitant administration of these drugs should be done with caution or be avoided if possible.

Hipomagnesemia secundaria a omeprazol / Hypomagnesaemia following omeprazole

La hipomagnesemia asociada al tratamiento crónico con inhibidores de la bomba de protones (IBP) es una entidad poco frecuente, aunque potencialmente grave. Su mecanismo continúa siendo desconocido. Cuando la magnesemia cae por debajo de 0,5 mEq/L, las manifestaciones clínicas neuromusculares y cardíacas pueden aparecer. En el momento agudo, la reposición precoz de magnesio y, en muchos casos, de otros iones como el calcio y el potasio, suele ser el tratamiento. Sin embargo, su normalización definitiva requiere, por lo general, la supresión del tratamiento con IBP.(AU)

Hypomagnesaemia associated with chronic treatment with Proton Pump Inhibitors (PPIs) is a rare entity, although potentially severe. Its mechanism remains unknown. When the magnesaemia falls below 0.5 mEq/L, neuromuscular and cardiac clinical manifestations may appear. At the acute stage, early replacement of magnesium and, in most cases, calcium and potassium, is usually the treatment. However, its definitive normalization requires the withdrawal of PPI treatment.(AU)

Gitelman Syndrome Presenting with Cerebellar Ataxia and Tetany.

Gitelman syndrome (GS) is salt-losing tubulopathy characterized by hypokalemia, hypomagnesemia, hypocalciuria, hyperreninemia, hyperaldosteronemia, metabolic alkalosis, and rarely hypocalcemia. Here, we describe the case of a 54-year-old man who presented with cerebellar signs and tetany. On investigation, he was found to have hypokalemia, hypocalcemia, hypomagnesemia, metabolic alkalosis, and high urinary chloride levels. On correction of metabolic parameters, he became asymptomatic. In cases of unexplained recurrent hypokalemia, hypocalcemia and hypomagnesemia, the diagnosis of GS should be considered.

Intramuscular hemorrhages in the pathway of an electric current through the body - two case reports.

Intramuscular hemorrhages at autopsy can have a variety of traumatic as well as non-traumatic causes, but their recognition in electrical deaths is almost a rarity. We report on two autopsy cases of electrical fatalities, the first relating to a portion of the right upper human extremity, consisting (only) of the forearm and hand, while the other case relates to a female child who died after a high voltage electrical shock. In both cases, layered dissection of the upper limb revealed fresh intramuscular hemorrhages in the skeletal muscles that could be topographically related to the path taken by the current through the body. Externally visible electric marks were present in both cases. The hemorrhages were most likely caused by current-induced tetanic muscle contractions, producing an internal muscle trauma with rupture of fibers and bleedings. In complex situations, such as inconspicuous marks or a complete lack of visible signs on the body, the finding may be helpful in solving the case in consideration of the case history and circumstances. The vitality, topography, and pattern of the hemorrhages are discussed in the light of the available literature.

MRI of a middle ear cholesteatoma in a cat.

A 9-year-old Maine coon cat presented with right-sided Horner and facial nerve paralysis. Magnetic resonance imaging (MRI) showed a heterogeneously contrast-enhancing mass occupying the right dorsolateral compartment of the tympanic cavity and extending into the ventromedial compartment, which was expanded and fluid filled. A ventral bulla osteotomy was performed to debulk the soft tissue mass. Histopathology revealed a cholesteatoma. The cat showed slow improvement of clinical signs and was euthanized eleven months postoperatively for unrelated causes. The MRI characteristics of middle ear cholesteatoma in the present case varied from those described in humans and dogs.

Radiocontrast-Diatrozate and Iopromide-Induced Severe Hypocalcemia Leading to Painful Tetanic and Severe Laryngeal Spasm: A Near Fatal Encounter.

Routinely advised radiological investigations like contrast-enhanced scans can have adverse effects on electrolyte imbalance due to the administration of Radiocontrast. Urograffin (Diatrizoate) and Ultravist (Iopromide) are some of the common examples of contrasts given to patients that possibly led to chelation of the calcium in serum causing severe carpopedal spasms and painful muscular tetany in our patient. Here we report a case of a 32-year-old female patient with acute gastroenteritis who presented with complaints of pain in the abdomen, multiple episodes of vomiting, and loose stools underwent contrast-enhanced computed tomography (CECT) scan of the abdomen, and developed severe painful muscular tetanic spasms after intravenous and oral contrast was administered.

Crisis celíaca y tetania aguda en pediatría. Reporte de un caso / Celiac crisis and acute tetany in pediatrics. Case report

RESUMEN La enfermedad celíaca es una enfermedad sistémica inmunomediada, con un gran espectro de presentaciones clínicas. El término crisis celíaca describe la forma aguda y potencialmente fatal. Clínicamente se caracteriza por diarrea severa, deshidratación y alteraciones metabólicas. Se reporta el caso de un paciente masculino de 7 años de edad que asiste a guardia con tetania, edema en miembros inferiores, esteatorrea y pérdida de peso de 8 meses de evolución, con hallazgos analíticos de hipocalcemia, hipomagnesemia, hipopotasemia y coagulopatía. El diagnóstico de crisis celíaca se realizó sobre la base de hallazgos serológicos y clínicos compatibles con enfermedad celíaca en el contexto de anomalías metabólicas graves y desnutrición aguda, confirmado posteriormente por anatomía patológica. La importancia de este reporte radica en repasar las características de esta grave entidad, que requiere un elevado índice de sospecha para su diagnóstico.

ABSTRACT Celiac disease is an immune-mediated systemic disease with a wide spectrum of clinical presentations. The term celiac crisis describes the acute and potentially fatal form. Clinically it is characterized by severe diarrhea, dehydration, and metabolic disturbances. The case of a 7-year-old male patient attending the ward with tetany, lower limb edema, steatorrhea and weight loss of 8 months of evolution is reported, with analytical findings of hypocalcemia, hypomagnesemia, hypokalemia and coagulopathy. The diagnosis of celiac crisis was made on the basis of serological and clinical findings compatible with celiac disease in the context of severe metabolic abnormalities and acute malnutrition, later confirmed by pathological anatomy. The importance of this report lies in reviewing the characteristics of this serious entity, which requires a high index of suspicion for its diagnosis.

Hyperemesis Gravidarum With Paraparesis and Tetany.

Subacute-onset muscle weakness can result from channelopathies, inflammatory myopathies, thyroid dysfunction, hypoparathyroidism, vitamin D deficiency, and dyselectrolytemias like hypokalemia, hypocalcemia, and hypomagnesemia. We report a curious and extremely rare case of a 29-year-old woman with hyperemesis gravidarum presenting with disabling muscle weakness involving her lower limbs and trunk, and concurrent features of tetany. Following voluminous vomiting over the last two months, she presented with history of weakness of her lower limbs of 14 days duration, resulting in difficulty in her getting out of bed or walking unassisted. On examination, she was hypotensive (80/60 mmHg) and tachycardic (110 bpm), with flaccid weakness of her lower limbs (proximal weakness more than distal weakness - power of 1/5 at the hips bilaterally, and 3/5 at the knees and ankles bilaterally) and diminished deep tendon reflexes. She also had positive Trousseau's sign and Chvostek's sign. Interestingly, she also had thinned-out bluish sclerae, a high-arched palate, short stature, and bilateral conductive hearing loss. Laboratory evaluation revealed anemia, hyponatremia, hypokalemia, hypomagnesemia, hypochloremia, hypophosphatemia, and low vitamin D levels. Electrocardiogram showed prolonged QT interval. Her thyroid function test and parathyroid levels were normal. With parenteral replenishment of the electrolytes and vitamin D, her power improved and she was discharged on oral supplements. Thus, this case report demonstrates the importance of aggressive, early, and adequate management of hyperemesis gravidarum to prevent dyselectrolytemia-associated paraparesis.

Migraine and Its Association with Hyperactivity of Cell Membranes in the Course of Latent Magnesium Deficiency-Preliminary Study of the Importance of the Latent Tetany Presence in the Migraine Pathogenesis.

So far, there is no consistent and convincing theory explaining the pathogenesis of migraines. Vascular disorders, the effect of oxidative stress on neurons, and the contribution of magnesium-calcium deficiencies in triggering cortical depression and abnormal glutaminergic neurotransmission are taken into account. However, there are no reliable publications confirming the role of dietary deficits of magnesium and latent tetany as factors triggering migraine attacks. The aim of the study was to evaluate the influence of latent magnesium deficiency assessed with the electrophysiological tetany test on the course of migraine. The study included: a group of 35 patients (29 women and six men; in mean age 41 years) with migraine and a control group of 24 (17 women and seven men; in mean age 39 years) healthy volunteers. Migraine diagnosis was based on the International Headache Society criteria, 3rd edition. All patients and controls after full general and neurological examination were subjected to a standard electrophysiological ischemic tetany test. Moreover, the level of magnesium in blood serum was tested and was in the normal range in all patients. Then, the incidence of a positive tetany EMG test results in the migraine group and the results in the subgroups with and without aura were compared to the results in the control group. Moreover, the relationship between clinical markers of spasmophilia and the results of the tetany test was investigated in the migraine group. As well as the relationship between migraine frequency and tetany test results. There was no statistically significant difference in the occurrence of the electrophysiological exponent of spasmophilia between the migraine and control group. Neither correlation between the occurrence of clinical symptoms nor the frequency of migraine attacks and the results of the tetany test was stated (p > 0.05). However, there was an apparent statistical difference between the subgroup of migraine patients with aura in relation to the control group (p < 0.05). The result raises hope to find a trigger for migraine attacks of this clinical form, the more that this factor may turn out to be easy to supplement with dietary supplementation.

Recurrent tetany in the course of metabolic alkalosis in patient with short bowel syndrome.

Not required for Clinical Vignette.

Magnesium biofortification of Italian ryegrass (Lolium multiflorum L.) via agronomy and breeding as a potential way to reduce grass tetany in grazing ruminants.

AIM: Magnesium (Mg) deficiency (known as grass tetany) is a serious metabolic disorder that affects grazing ruminants. We tested whether Mg-fertiliser can increase Mg concentration of Italian ryegrasses (Lolium multiflorum L.) including a cultivar (cv. Bb2067; 'Magnet'), bred to accumulate larger concentrations of Mg. METHODS: Under controlled environment (CE) conditions, three cultivars (cv. Bb2067, cv. Bb2068, cv. RvP) were grown in low-nutrient compost at six fertiliser rates (0-1500 µM MgCl2.6H2O). Under field conditions, the three cultivars in the CE condition and cv. Alamo were grown at two sites, and four rates of MgSO4 fertiliser application rates (0-200 kg ha-1 MgO). Multiple grass cuts were taken over two-years. RESULTS: Grass Mg concentration increased with increasing Mg-fertiliser application rates in all cultivars and conditions. Under field conditions, cv. Bb2067 had 11-73% greater grass Mg concentration and smaller forage tetany index (FTI) than other cultivars across the Mg-fertiliser application rates, sites and cuts. Grass dry matter (DM) yield of cv. Bb2067 was significantly (p < 0.05) smaller than cv. Alamo. The effect of Mg-fertiliser rate on DM yield was not significant (p ≥ 0.05). CONCLUSIONS: Biofortification of grass with Mg through breeding and agronomy can improve the forage Mg concentration for grazing ruminants, even in high-growth spring grass conditions when hypomagnesaemia is most prevalent. Response to agronomic biofortification varied with cultivar, Mg-fertiliser rate, site and weather. The cost:benefit of these approaches and farmer acceptability, and the impact on cattle and sheep grazing on grasses biofortified with Mg requires further investigation.

Neuromuscular tetanic hyperexcitability syndrome associated to a heterozygous Kv1.1 N255D mutation with normal serum magnesium levels.

Mutations of the main voltage-gated K channel members Kv1.1 are linked to several clinical conditions, such as periodic ataxia type 1, myokymia and seizure disorders. Due to their role in active magnesium reabsorption through the renal distal convoluted tubule segment, mutations in the KCNA1 gene encoding for Kv1.1 has been associated with hypomagnesemia with myokymia and tetanic crises. Here we describe a case of a young female patient who came to our attention for a history of muscular spasms, tetanic episodes and muscle weakness, initially misdiagnosed for fibromyalgia. After a genetic screening she was found to be carrier of the c.736A > G (p.Asn255Asp) mutation in KCNA1, previously described in a family with autosomal dominant hypomagnesemia with muscular spasms, myokymia and tetanic episodes. However, our patient has always presented normal serum and urinary magnesium values, whereas she was affected by hypocalcemia. Calcium supplementation gave only partial clinical benefit, with an improvement on tetanic episodes yet without a clinical remission of her spasms, whereas magnesium supplementation worsened her muscular symptomatology.

Tingles, Tetany, and Electrolyte Derangements.

We report a patient who presented with anxiety, hyperventilation, perioral paresthesia, and tingling in the fingers associated with hypomagnesemia, hypocalcemia, and hypokalemia. We discuss the possible mechanistic basis for sequence of events that may have led to this presentation.