Rare Case of Severe Hypocalcemia Due to PTH Resistance Related to Diet Pill

Abstract Introduction: The production of parathyroid hormone (PTH) is essential for calcium the maintenance of normal mineral metabolism. Parathyroid cells have cell-surface calciumsensing receptors, even small changes in extracellular Ca induce rapid changes in PTH secretion. Hypocalcaemia is a well-recognized manifestation of magnesium deficiency. We present rare case of severe hypocalcemia due to PTH resistance caused by hypomagnesemia related to diet pill. Case Report: 61 year old Hispanic obese female with chronic gastritis on omeprazole 20 mg daily, no other significant past medical and surgical history, not taking any prescribed medications presents to ED with complaints of tingling and numbness around the mouth, abdominal cramps, chest pain, shortness of breath and anxiety. On arrival calcium was found to be 6.0mg/dl(8.2–10.2mg/dl) with ionized calcium of 0.60mmol/l(1.13-1.32mmol/l) and EGFR>90ml/min, Albumin-4.0g/l, Magnesium-1.1mg/dl(1.6–2.3mg/dl), Phosphorus-6.1mg/dl(2.4–4.5mg/dl),rest of the electrolytes were normal. Patient was given IV calcium gluconate 2g and magnesium which helped improving her symptoms. PTH was 1700pg/ml(23-73pg/ml), low Vitamin D 25-hydroxy 20ng/dl(30-100ng/dl). Urinary calcium was <1mg/dl(2.0–17.5mg/dl). Vitamin D1,25- dihydroxy 34pg/ml(18-78pg/ml), PTH-like peptide levels 0.6pmol/l(<4.2pmol/l). EKG was normal no QT interval changes. For 4 weekspatient was taking weight loss medication was given to her by her brother called nucific-bio-x4. Patient had lost 4 pounds while taking the medication and had suppression of appetite. Physical features of pseudohypoparathyroidism were not seen. Patient had poor dietary intake of calcium, denied taking vitamin D supplements. Patient was given calcium acetate 2001 mg TID with meals, calcitriol 0.5mcg daily and calcium gluconate 2g IV intermittently was given. That improved her calcium levels to 6.8mg/dl with ionized calcium-0.90mmol/l. Magnesium was replaced IV and discharged on magnesium oxide 400mg BID to maintain magnesium the normal range. The patient was given loading dose of ergocalciferol 50,000 IUfor 8 weeks. At the time of discharge repeat PTH levels were 1600 pg/ml and calcium levels were 8.2mg/dl. 3D CT of the neck did not parathyroid mass. After discharge patient continued on oral calcium and magnesium to maintain calcium levels between 8.4–10.2mg/dl. After discharge calcium levels were 8.6mg/dl, vitamin D 25-hydroxy levels were 32ng/dl and maintenance dose of vitamin D3 2000 IU daily also continued. Nucific-bio-x4 pill was discontinued. Conclusion: In conclusion, severe life threatening hypocalcemia can occur with unsupervised weight lossmedications due to malabsorption of magnesium in patient with likely mutation in magnesium receptors causing PTH resistance. Vitamin D deficiency worsens hypocalcemia resulting into secondary hyperparathyroidism.

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Bone and Mineral Metabolism in Patients with Primary Aldosteronism

International Journal of Endocrinology ◽

10.1155/2014/836529 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 34

Author(s):

Luigi Petramala ◽

Laura Zinnamosca ◽

Amina Settevendemmie ◽

Cristiano Marinelli ◽

Matteo Nardi ◽

...

Keyword(s):

Vitamin D ◽

Primary Aldosteronism ◽

Mineral Metabolism ◽

Urinary Calcium ◽

Urinary Calcium Excretion ◽

Calcium Excretion ◽

Mineral Density ◽

Lower Serum ◽

Functional Link ◽

The Impact

Primary aldosteronism represents major cause of secondary hypertension, strongly associated with high cardiovascular morbidity and mortality. Aldosterone excess may influence mineral homeostasis, through higher urinary calcium excretion inducing secondary increase of parathyroid hormone. Recently, in a cohort of PA patients a significant increase of primary hyperparathyroidism was found, suggesting a bidirectional functional link between the adrenal and parathyroid glands. The aim of this study was to evaluate the impact of aldosterone excess on mineral metabolism and bone mass density. In 73 PA patients we evaluated anthropometric and biochemical parameters, renin-angiotensin-aldosterone system, calcium-phosphorus metabolism, and bone mineral density; control groups were 73 essential hypertension (EH) subjects and 40 healthy subjects. Compared to HS and EH, PA subjects had significantly lower serum calcium levels and higher urinary calcium excretion. Moreover, PA patients showed higher plasma PTH, lower serum 25(OH)-vitamin D levels, higher prevalence of vitamin D deficiency (65% versus 25% and 25%;P<0.001), and higher prevalence of osteopenia/osteoporosis (38.5 and 10.5%) than EH (28% and 4%) and NS (25% and 5%), respectively. This study supports the hypothesis that bone loss and fracture risk in PA patients are potentially the result of aldosterone mediated hypercalciuria and the consecutive secondary hyperparathyroidism.

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SAT-371 Severe Hypocalcemia Secondary to Pseudohypoparathyroidism

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.051 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Neelima Ghanta ◽

Derick Adams

Keyword(s):

Vitamin D ◽

Calcium Carbonate ◽

Rare Disorder ◽

Ionized Calcium ◽

Thyroid Function Tests ◽

Intact Pth ◽

Free T4 ◽

Vitamin D Levels ◽

Gnas Gene ◽

Pth Resistance

Abstract Introduction: Pseudohypoparathyroidism (PHP) is a rare disorder characterized by PTH resistance due to a mutation in the GNAS gene causing decreased cyclic AMP generation. The 5 subtypes of PHP include type 1a, 1b, 1c, 2, and pseudo-PHP with type 1a being the most common. Patients with PHP present with hypocalcemia, hyperphosphatemia, appropriately elevated PTH, and suppressed calcitriol levels. PHP type 1a patients have characteristic features including obesity, short stature, round facies, and shortened metacarpals. PHP patients should be evaluated for other endocrinopathies as mutations in the GNAS gene may result in resistance to other hormones like TSH, GHRH, and gonadotropins. Case Report: This patient is a 25 year old male who presented to clinic for evaluation of hypocalcemia. He denied any personal or family history of calcium disorders, thyroid disease, or parathyroid disease. He admitted to severe fatigue and muscle cramps for over one year leading to a car accident. He was sent to the emergency room and diagnosed with hypocalcemia requiring IV calcium gluconate. He was then seen by his family physician and was found to have elevated intact PTH and low 25-hydroxy vitamin D levels. He was placed on cholecalciferol 5000 international units (IU) daily, ergocalciferol 50,000 IU once weekly, calcium carbonate 500 mg (6 tablets daily), and referred to endocrinology. The physical exam was unremarkable. The laboratory values tested were an intact PTH of 645 pg/mL (10–65 pg/mL), ionized calcium of 4.2 mg/dL (4.6–5.08 mg/dL), magnesium of 2.1 mg/dL (1.5–2.3 mg/dL), 25-OH vitamin D of 31.7 ng/mL (20–100 ng/mL), and creatinine of 0.81 mg/dL (0.7–1.3 mg/dL) four months after starting the above mentioned calcium and vitamin D supplementation. Further testing revealed a phosphorus level of 4.8 mg/dL (2.3–4.7 mg/dL), calcitriol level of 55.8 pg/mL(19.9–79.3 pg/mL), TSH of 10.46 uIU/mL (0.4–4.2 uIU/mL) and free T4 of 1.5 ng/dL (0.8–1.7 ng/dL). His labs were consistent with PHP. Although unknown which PHP subtype, it is likely not type 1a as he lacks its characteristic phenotype. His abnormal thyroid function tests may be secondary to TSH resistance associated with the GNAS gene mutation. He was told to continue the current dose of calcium carbonate but to discontinue ergocalciferol and cholecalciferol. He was placed on calcitriol 0.5 mcg daily. He will have repeat levels of his ionized calcium, calcitriol, TSH, and free T4 in two weeks. If TSH is still above 10 uIU/mL, we will start levothyroxine replacement. Conclusion: Although a rare disorder, clinicians should have a high index of suspicion for PHP to prevent complications of hypocalcemia (tetany, arrhythmias, seizures) and metabolic bone disease from PTH resistance. References: Mantovani, G. Pseudohypoparathyroidism: Diagnosis and Treatment, The Journal of Clinical Endocrinology & Metabolism, Volume 96, Issue 10, 1 October 2011, Pages 3020–3030.

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Abstract P389: Effects of Dietary Patterns on Vitamin D and Other Markers of Bone-Mineral Metabolism: Results From the Dash Trial

Circulation ◽

10.1161/circ.131.suppl_1.p389 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Ahmed Hassoon ◽

Lawrence Appel ◽

Edgar Miller

Keyword(s):

Vitamin D ◽

Bone Mineral ◽

Mineral Metabolism ◽

Control Diet ◽

Urinary Calcium ◽

Blood Levels ◽

Dash Diet ◽

Bone Mineral Metabolism ◽

Vitamin D Levels ◽

Total Fat

Background: The relationship of CVD with vitamin D levels and other markers of bone-mineral metabolism is of substantial interest. The Dietary Approaches to Stop Hypertension (DASH) diet effectively lowers blood pressure and is now recommended to promote CV health. The effects of the DASH diet on vitamin D and other markers of bone-mineral metabolism is unknown. Objective: To determine the effect of dietary patterns on blood levels of vitamin D, PTH, and ionized calcium, and urinary excretion of calcium and phosphate. Methods: Data on study outcomes were available in 334 participants from the original DASH trial. Baseline levels were obtained from blood and urine collected at the end of the run-in while on the control diet. Participants were then randomized to control diet (37% kcal total fat); fruits & vegetable diet (also 37% kcal total fat); or the DASH diet (27% kcal total fat). Follow-up levels were obtained during the last week of the eight-week intervention period. Results: Mean (±SD) baseline blood levels of vitamin D, PTH , and ionized calcium were 15.1±3.7ng/ml, 46.1±18.5 ng/ml and 1.3±0.06 mmol/l, respectively. For urinary calcium and phosphate were 126.8±45.3mg/dl and 715.0±277.3 mg/dl, respectively. See table for within-diet changes. The DASH diet, net of control, reduced vitamin D by -1.29ng/ml (P= 0.005). In stratified analyses, the reduction in vitamin D appeared more prominent in blacks, but the p-value for interaction (race*diet) was non-significant (P=0.21). Otherwise, the DASH diet had no significant effect on the other markers, net of control. Compared to control, the fruit & vegetable diet reduced urinary calcium and phosphorus excretion. Conclusion: The DASH diet modestly reduced vitamin D levels among all participants, with potentially larger effects in blacks. The reduction in vitamin D levels might have resulted from the lower fat content of the DASH diet. Overall, during the eight-weeks of intervention, no major harm or benefit of the DASH diet was documented on biomarkers related to bone-mineral metabolism.

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Vitamin-D status and mineral metabolism in two ethnic populations with sarcoidosis

Journal of Investigative Medicine ◽

10.1136/jim-2016-000101 ◽

2016 ◽

Vol 64 (5) ◽

pp. 1025-1034 ◽

Cited By ~ 9

Author(s):

Giovanna Capolongo ◽

Li Hao Richie Xu ◽

Mariasofia Accardo ◽

Alessandro Sanduzzi ◽

Anna Agnese Stanziola ◽

...

Keyword(s):

Vitamin D ◽

Vitamin D Deficiency ◽

Mineral Metabolism ◽

Serum Vitamin ◽

Urinary Calcium ◽

Calcium Excretion ◽

Calcium Balance ◽

Serum Vitamin D ◽

Vitamin D Levels ◽

Caucasian Patients

Vitamin-D insufficiency and sarcoidosis are more common and severe in African Americans (AA) than Caucasians. In sarcoidosis, substrate-dependent extrarenal 1,25-dihydroxyvitamin-D (1,25-(OH)2D) production is thought to contribute to hypercalciuria and hypercalcemia, and vitamin-D repletion is often avoided. However, the anti-inflammatory properties of vitamin-D may also be beneficial. We prospectively examined serum vitamin-D levels, calcium balance, and the effects of vitamin-D repletion in 86 AA and Caucasian patients with biopsy-proven active sarcoidosis from the USA (US) and Italy (IT) in university-affiliated outpatient clinics. Clinical features, pulmonary function, and calciotropic hormones were measured. 16 patients with vitamin-D deficiency and normal serum ionized calcium (Ca2+) were treated with oral ergocalciferol (50,000 IU/week) for 12 weeks. Baseline mineral parameters were similar in US (93% AA) and IT (95% Caucasian) patients irrespective of glucocorticoid treatment. Pulmonary dysfunction was less pronounced in IT patients. Nephrolithiasis (in 11% US, 17% IT patients) was associated with higher urinary calcium excretion. Vitamin-D deficiency was not more prevalent in patients compared to the respective general populations. As serum 25-hydroxyvitamin-D (25-OHD) rose postrepletion, serum 1,25-(OH)2D, γ-globulins, and the previously elevated angiotensin converting enzyme (ACE) levels declined. Asymptomatic reversible increases in Ca2+or urinary calcium/creatinine (Ca/Cr) developed in three patients during repletion. In conclusion, Caucasian and AA patients show similar calcium and vitamin D profiles. The higher prevalence of hypercalciuria and nephrolithiasis in sarcoidosis is unrelated to endogenous vitamin-D levels. Vitamin-D repletion in sarcoidosis is generally safe, although calcium balance should be monitored. A hypothesis that 25-OHD repletion suppresses granulomatous immune activity is provided.

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Relationship Between Nutrient Intake and Vitamin D Status in Osteoporotic Women

International Journal for Vitamin and Nutrition Research ◽

10.1024/0300-9831.77.6.376 ◽

2007 ◽

Vol 77 (6) ◽

pp. 376-381 ◽

Cited By ~ 12

Author(s):

de Souza Genaro ◽

de Paiva Pereira ◽

de Medeiros Pinheiro ◽

Szejnfeld ◽

Araújo Martini

Keyword(s):

Vitamin D ◽

Mineral Metabolism ◽

Sodium Intake ◽

Serum Vitamin ◽

Cross Sectional Study ◽

Dietary Intakes ◽

Mineral Density ◽

Cross Sectional ◽

Serum Vitamin D ◽

Dietary Records

Vitamin D is essential for maintaining calcium homeostasis and optimizing bone health. Its inadequacy is related to many factors including dietary intake. The aim of the present study was to evaluate serum 25(OH)D and its relationship with nutrient intakes in postmenopausal Brazilian women with osteoporosis. This cross-sectional study comprised 45 free-living and assisted elderly at São Paulo Hospital. Three-day dietary records were used to assess dietary intakes. Bone mineral density was measured with a dual-energy X-ray absorptiometer (DXA). Blood and urine sample were collected for analysis of biochemical markers of bone and mineral metabolism. Insufficiency of vitamin D was observed in 24.4% of the women and optimal levels (≥ 50 nmol/L) were observed in 75.6%. Parathyroid hormone was above the reference range in 51% of the participants. The mean calcium (724 mg/day) and vitamin D (4.2 μ g/day) intakes were lower than the value proposed by The Food and Nutrition Board and sodium intake was more than two-fold above the recommendation. Higher levels of serum 25(OH)D were inversely associated with sodium intake. Dietary strategies to improve serum vitamin D must focus on increasing vitamin D intake and should take a reduction of sodium intake into consideration.

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Vitamin D Provision in High-Yield Dairy Cows During the Winter Housing Period

Agricultural science and practice ◽

10.15407/agrisp1.01.042 ◽

2014 ◽

Vol 1 (1) ◽

pp. 42-46

Author(s):

L. Yuskiv ◽

V. Vlizlo

Keyword(s):

Vitamin D ◽

Alkaline Phosphatase Level ◽

Mineral Metabolism ◽

Physiological State ◽

Blood Parameters ◽

Postnatal Period ◽

High Yield ◽

Oral Supplementation ◽

Calcium Phosphorus ◽

Vitamin D 3

Aim. To investigate the vitamin D status in highly productive cows during winter housing period and effect of cholecalciferol by various ways of vitamin D 3 injection to cows in last days of gestation and after calving. Methods. Enzyme-linked immunoassay, spectrophotometry. Results. It has been stated that intramuscular injection of cholecalciferol into cows caused increase of the vitamin D 3 active metabolite – 25-OHD 3 , calcium, phosphorus and magnesium levels together with decrease of alkaline phosphatase level in pre- and post-natal periods. Oral supplementation makes little infl uence on the studied blood parameters of cows. Conclusions. Extrabuccal administration and oral supplementation of cholecalciferol in winter housing period to high-yield cows in the last days of gestation and after calving is accompanied by increased levels of its metabolites and their effect on mineral metabolism in the postnatal period. The nature of these changes depends on the mode of vitamin D administration and the physiological state of the cows.

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Blood Parathyrin and Mineral Metabolism Dynamics. A clinical analyze

Revista de Chimie ◽

10.37358/rc.18.10.6619 ◽

2018 ◽

Vol 69 (10) ◽

pp. 2754-2758

Author(s):

Lucretiu Radu ◽

Mara Carsote ◽

Ancuta Augustina Gheorghisan Galateanu ◽

Smaranda Adelina Preda ◽

Veronica Calborean ◽

...

Keyword(s):

Case Control Study ◽

Mineral Metabolism ◽

Lumbar Bone Mineral Density ◽

Urinary Calcium ◽

Mineral Density ◽

Cross Sectional ◽

X Ray ◽

Menopausal Women ◽

Ionic Calcium ◽

Control Study

Circulating parathyrin (PTH or parthormon) is increased in primary hyperparathyroidism (PHP) in association with high total/ionic calcium (T/I Ca) and others mineral metabolism anomalies. This is a clinical cross-sectional and case-control study analyzing these changes after PHP surgical correction in menopausal women. Baseline parameters were: mean age at diagnosis (59.63�9.6 years), TCa of 10.9�0.7 mg/dL, PTH of 138.02�59.36 pg/mL. Longitudinal data showed: final TCa p[0.00001, ICa p[0.00001, phosphorus p[0.0001, magnesium p=0.9, 24-h urinary calcium p=0.4, 25-hydroxycholecalciferol p=0.01, PTH p[0.00001. High circulating parathyrin values due to PHP normalized after surgery in addition to statistical significant changes of TCa, ICa, P, lumbar Bone Mineral Density provided by Dual-Energy X-Ray Absorptiometry; Mg and 24-h Ca might not be a marker of general mineral metabolism improvement.

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