hypocalcemia 2017 case scenario

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  1. 1. Approach to hypocalcemia in children Dr.Yassin M. Al-saleh
  2. 2. Case scenario 1 8 years old girl presented with history of vomiting.
  3. 3. Case scenario History of organophosphorus poisoning (spray ) to hair . There is history of frequent twitching of the hand over last one month. Perinatal, past medical and surgical ,blood transfusion :unremarkable Medication: unremarkable Development: good in school. Family history: unremarkable for autoimmune or inherited disease.
  4. 4. On exam: Not dysmorphic. no hypo or hyperpigmentation Wt:75th HT:75th Vital sign normal No goitre Chevostic +ve.
  5. 5. Initial impression :Hypocalcemia Differential diagnosis Hypoparathyrodism (isolated). Hypoparathyrodism (APS). Pseudohypoparathyrodism. CKD. Vit d deficiency.(nutritional). Hypomagnesemia. kyperventilation
  6. 6. Investigation Biochem: na ,k ,cl WNL Renal :BUN and creatinine WNL Ca:1.6 , albumin 38 phosphrus 3, Mg:0.7 WNL ALK 120 N PTH: 330 high Urine for ca: low Vit d level: 15 ng/dl (20-30) LFT:WNL. VBG: WNL Renal US: WNL
  7. 7. impression Pseudohypoparathyrodism 2B Treatment: One alpha or calctriol Calcium
  8. 8. Hypocalcemia Normal level of calcium : 2.3-2.7 mmol/l Hypocalcemia Decrease inflow of calcium to circulatory compartment from intestine, bone or kidney. Increase excretion from intestine or kidney.
  9. 9. causes of hypocalcemia in children other Pseudohypoparathyroidis m classified as type 1 A,B,C , type II Vitamin D disorders ( nutritional or inherited) Hungry bone syndrome Medication ( high mg, bisphosphonate, Lasix High phosphate Pancreatitis Mal absorption Hypoparathyroidism isolated (autoimmune) part of syndrome (APS1) complex congenital anomalies like Disgorge, SSS, barakate syndrome sporadic or familial AR or AD defect in parathyroid gland development defects in parathyroid hormone synthesis or secretion familial hypercalcuric hypocalcemia Acquired (surgical removal or vascular injury, storage accumulation like iron, copper granulomatous diseases or irradiation
  10. 10. History Symptoms of hypocalcemia Hx of recurrent infection ( Digeorge), deafness ( barakat), any other endocrine disorders ( APS1 ) Hx of recurrent blood Tx ( iron deposition ). Hx of previous irradiation or surgery Hx for Vit D ( diet, sun exposure and prophylaxis vit D Hx of medication Family Hx of poly endocrinopathy, nephrocalcinosis, hypoparathyroidism
  11. 11. Physical examination Well or ill, jaundice, dysmorphology, hyperpigmentation Growth parameter Vital sign Hand and nail dystrophy (APS1), wide wrist ( Ricket), goiter, oral candidiasis, CVS murmur Skin : vitiligo and alopecia
  12. 12. investigation Bone and renal profile PTH if low or realtively low (hypoparathyroidism either congenital or acquired ) If high PTH either vit D disorders, renal failure or pseudo hypoparathyroidism
  13. 13. management In acute hypocalcemia give elemental ca 10- 20 mg/kg ( 1-2 ml/kg ca gluconate) over 10 min, then continuous infusion under cardiac monitor After stabilization treat according to the cause.
  14. 14. Case scenario 2 One month with abnormal movement.
  15. 15. Case scenario 2 Abnormal movement for one day Active ,feeding well, Perinatal, past medical and surgical ,blood transfusion :unremarkable Medication: unremarkable Development: smile Family history: unremarkable for autoimmune or inherited disease.
  16. 16. On exam: soft dysmorphic. Depressed nasal bridge. no hypo or hyperpigmentation Wt:10th HT:10th Vital sign normal CVS:murmur
  17. 17. Initial impression :abnormal movement Differential diagnosis Hypocalcemia Hypoparathyrodism, Pseudohypoparathyrodism. Vit d deficiency.(nutritional or inherited). Hypomagnesemia or hypermagnesemia Hypoglycemia, hyponatremia, Sepsis, seizure disorder, metabolic disease.
  18. 18. investigation Biochem: na ,k ,cl WNL Renal :BUN and creatinine WNL Ca:1.6 , albumin 38 phosphrus 3, Mg:0.7 WNL ALK 120 N PTH: normal Urine for ca: low Vit d level: 22 ng/dl (20-30) LFT:WNL. VBG: WNL ECHO: VSD FISH: digorge
  19. 19. impression Hypoparathyrodism Digorge
  20. 20. The causes of early neonatal hypocalcemia Prematurity Low birth weight Asphyxia Infant of diabetic mother Hypoparathyroidism Maternal hyperparathyroidism Maternal intake of calcium Neonatal jaundice requiring phototherapy or exchange transfusion Metabolic or respiratory alkalosis Medication: NaHco3, chelating agent ( like citrate in blood transfusion, phosphate, soy milk), aminoglycosides Osteopetrosis
  21. 21. The causes of late neonatal hypocalcemia High phosphate Low or high mg Vitamin D disorder Hypoparathyroidism either transient or permanent PTH receptor anbnormality Mitochondrial disorders ( Kearen Sayer syndrome, MELAS
  22. 22. History - Symptoms of hypocalcemia ( seizure, feeding intolerance etc) - Prenatal Hx: parity ( multipara), maternal illnesses ( like DM, GDM, hyperparathyroidism, toxemia) , medication ( ca carbonate , mg) - Perinatal Hx: mode of delivery, term or preterm, birth weight and apgar score - Postnatal Hx: jaundice, medication (aminoglycoside, NaHco3 etc), blood transfusion, high Po4 formula, sepsis - Family and social Hx: family member with hypocalcemia, dysmorphic, renal calculi, reckit, seizure disorder, maternal Hx of sun exposure and her diet
  23. 23. Physical examination: - Well or ill, term or preterm, jaundice, dysmorphic features - Growth parameter - Vital signs ( fever, hypotensive ? sepsis) - Signs of ricket - CVS : murmur
  24. 24. Lab Chemistry: BUN & creatinine ( renal failure), PH alkalosis) Ca, po4, mg, ALK Urine for calcium: creatinine ratio PTH level Low calcidiol level indicate (maternal low Vit D or rarely 25 hydroxylase mutation) Low calcitriol indicate ( hypoparathyroidism, defect in one alfa hydroxylase or severly compromised renal failure) High calcitriol indicate Vit D resistant
  25. 25. Imaging - Skeletal survey : rickets sign, dysplasia or osteopetrosis - Chest X- ray thymic shadow ( disgorge)
  26. 26. management In acute hypocalcemia give elemental ca 10- 20 mg/kg ( 1-2 ml/kg ca gluconate) over 10 min, then continuous infusion under cardiac monitor After stabilization treat according to the cause.

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