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CMDT 2008
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gling of the circumoral area, hands, and feet is almost always present Symptoms of the chronic disease are lethargy, personality changes, anxiety state, blurring of vision due to cataracts, parkinsonism, and mental retardation Chvostek s sign (facial muscle contraction on tapping the facial nerve in front of the ear) is positive, and Trousseau s phenomenon (carpal spasm after application of a cuff) is present Cataracts may occur; the nails may be thin and brittle; the skin is dry and scaly, at times with fungus infection (candidiasis), and there may be loss of hair (eyebrows); and deep tendon reflexes may be hyperactive Papilledema and elevated cerebrospinal fluid pressure are occasionally seen Teeth may be defective if the onset of the disease occurs in childhood
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B Laboratory Findings
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Serum calcium is low, serum phosphate high, urinary calcium low, and alkaline phosphatase normal Serum calcium is largely bound to albumin In hypoalbuminemia, the serum ionized calcium may be determined, but it has had surprisingly poor clinical utility Alternatively, the serum calcium level can be corrected for serum albumin level as follows: Corrected serum Ca = Serum Ca mg/dL + (08 [40 Albumin g/dL]) PTH levels are low Serum magnesium should be determined since hypomagnesemia frequently accompanies hypocalcemia and may exacerbate symptoms and decrease parathyroid function
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Radiographs or CT scans of the skull may show basal ganglia calcifications; the bones may be denser than normal Cutaneous calcification may occur
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Slit-lamp examination may show early posterior lenticular cataract formation The electrocardiogram (ECG) shows prolonged QT intervals and T wave abnormalities Patients with chronic hypoparathyroidism tend to have increased bone mineral density, particularly in the lumbar spine
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Acute tetany with stridor, especially if associated with vocal cord palsy, may lead to respiratory obstruction requiring tracheostomy The complications of chronic hypoparathyroidism largely depend on the duration of the disease There may be associated autoimmunity causing sprue syndrome, pernicious anemia, or Addison s disease In long-standing cases, cataract formation and calcification of the basal ganglia are seen Occasionally, parkinsonian symptoms or choreoathetosis develop Ossification of the paravertebral ligaments may occur with nerve root compression; surgical decompression may be required Seizures are common in untreated patients Overtreatment with vitamin D and calcium may produce nephrocalcinosis and impairment of renal function
Clinical Findings
A Symptoms and Signs
Acute hypoparathyroidism causes tetany, with muscle cramps, irritability, carpopedal spasm, and convulsions; tin-
CMDT 2008
2 Intravenous calcium gluconate Calcium gluconate, 10 20 mL of 10% solution intravenously, may be given slowly until tetany ceases Ten to 50 mL of 10% calcium gluconate may be added to 1 L of 5% glucose in water or saline and administered by slow intravenous drip The rate should be adjusted so that the serum calcium is maintained between 8 mg/dL and 9 mg/dL 3 Oral calcium Calcium salts should be given orally as soon as possible to supply 1 2 g of calcium daily Liquid calcium carbonate (Titralac Plus), 500 mg/5 mL, may be especially useful The dosage is 1 3 g calcium daily Calcium citrate contains 21% calcium, but a higher proportion is absorbed with less gastrointestinal intolerance 4 Vitamin D preparations (Table 26 9) Therapy should be started as soon as oral calcium is begun The active metabolite of vitamin D, 1,25-dihydroxycholecalciferol (calcitriol), has a very rapid onset of action, and if toxicity develops it is not long-lasting It is of great use in the treatment of acute hypocalcemia Therapy is commenced at a dosage of 025 mcg orally each morning with upward dosage titration to near normocalcemia Ultimately, doses of 05 2 mcg/d are usually required Calcifediol (25-hydroxyvitamin D3), another option for treatment, has an intermediate onset and duration of action; the usual starting dose is 20 mcg/d orally 5 Magnesium If hypomagnesemia is present (chronic alcoholism, malnutrition, renal loss, drugs such as cisplatin, etc), it must be corrected to treat the resulting hypocalcemia Acutely, magnesium sulfate is given intravenously, 1 2 g every 6 hours Long-term magnesium replacement may be given as magnesium oxide tablets (600 mg), one or two per day, or as a combined magnesium and calcium preparation (Dolomite, others) 6 Transplantation of cryopreserved parathyroid tissue removed during prior surgery Transplantation restores normocalcemia in about 23% of cases
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