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A 76-year-old woman with electrolyte abnormalities
EJINME-03424; No of Page 1 European Journal of Internal Medicine xxx (2016) xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
A 76-year-old woman with electrolyte abnormalities Arno J. Gingele, Daan J.L. van Twist ⁎ Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
a r t i c l e
i n f o
Article history: Received 27 October 2016 Accepted 7 December 2016 Available online xxxx Keywords: Hypocalcaemia Trousseau sign
1. Case presentation A 76-year-old female was admitted to our hospital because of severe diarrhea and lethargy. Diarrhea persisted since several weeks. Past medical history revealed cholecystectomy, appendectomy, coronary artery bypass surgery, and hypertension. Palpation of the right hemi abdomen was slightly painful. No pathologic findings could be detected with abdominal ultrasound, abdominal X-ray, and computed tomography of the cerebrum. Laboratory tests revealed several electrolyte abnormalities. The clinical chemist, however, suspected that a laboratory error had occurred and suggested to repeat the test. In order to start electrolyte supplementation as soon as possible, we tried to verify the electrolyte abnormality without waiting for the second test. Hence, a blood pressure cuff was placed around her right arm and inflated to a pressure above systolic blood pressure (Video 1).
albumin (37.7 g/l; reference value 32–47 g/l), and parathyroid hormone level (3.3 pmol/l; reference value1.3–6.8 pmol/l) were normal. Presumably, hypocalcaemia was the result of relative hypoparathyroidism caused by severe hypomagnesaemia (0.17 mmol/l; reference value 0.7–1.0 mmol/l) due to fecal loss. Severe hypomagnesaemia interferes with the parathyroid calcium-sensing receptor [3], resulting in relative hypoparathyroidism, i.e. parathyroid hormone secretion is insufficient to maintain normal serum calcium levels. Because of the presence of Trousseau sign, calcium and magnesium supplementation was started immediately. As a result calcium and magnesium levels normalized and parathyroid hormone levels increased to 17.0 pmol/l. After treatment with metronidazole, diarrhea ceased. This case shows how Trousseau sign could be used to verify deviant calcium levels in clinical practice. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ejim.2016.12.007. Conflict of interest/disclosures None. References [1] Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336(7656):1298–302. [2] Urbano FL. Signs of hypocalcemia: Chvostek's and Trousseau's signs. Wayne, PA: Turner White Communications Inc.; 2000Hospital Physician. [3] Shoback DM, Bilezikian JP, Costa AG, Dempster D, Dralle H, Khan AA, et al. Presentation of hypoparathyroidism: etiologies and clinical features. J Clin Endocrinol Metab 2016;101(6):2300–12.
2. What is your diagnosis? 2.1. Diagnosis As shown in the video, flection of the wrist, extension of the interphalangeal joints and adduction of the fingers occurred. This phenomenon is known as Trousseau sign, which is typical for hypocalcaemia [1]. The described muscle contraction is the result of increased neural excitability due to hypocalcaemia, enforced by ischemia due to the inflated blood pressure cuff and can be found in 94% of all patients with hypocalcaemia [2]. In this case, laboratory tests indeed confirmed a very low total calcium level of 1.36 mmol/l (reference value 2.10–2.55 mmol/l). Serum ⁎ Corresponding author at: Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands. E-mail address: [email protected] (D.J.L. van Twist).
http://dx.doi.org/10.1016/j.ejim.2016.12.007 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Gingele AJ, van Twist DJL, A 76-year-old woman with electrolyte abnormalities, Eur J Intern Med (2016), http:// dx.doi.org/10.1016/j.ejim.2016.12.007
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
A 76-year-old woman with electrolyte abnormalities Arno J. Gingele, Daan J.L. van Twist ⁎ Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
a r t i c l e
i n f o
Article history: Received 27 October 2016 Accepted 7 December 2016 Available online xxxx Keywords: Hypocalcaemia Trousseau sign
1. Case presentation A 76-year-old female was admitted to our hospital because of severe diarrhea and lethargy. Diarrhea persisted since several weeks. Past medical history revealed cholecystectomy, appendectomy, coronary artery bypass surgery, and hypertension. Palpation of the right hemi abdomen was slightly painful. No pathologic findings could be detected with abdominal ultrasound, abdominal X-ray, and computed tomography of the cerebrum. Laboratory tests revealed several electrolyte abnormalities. The clinical chemist, however, suspected that a laboratory error had occurred and suggested to repeat the test. In order to start electrolyte supplementation as soon as possible, we tried to verify the electrolyte abnormality without waiting for the second test. Hence, a blood pressure cuff was placed around her right arm and inflated to a pressure above systolic blood pressure (Video 1).
albumin (37.7 g/l; reference value 32–47 g/l), and parathyroid hormone level (3.3 pmol/l; reference value1.3–6.8 pmol/l) were normal. Presumably, hypocalcaemia was the result of relative hypoparathyroidism caused by severe hypomagnesaemia (0.17 mmol/l; reference value 0.7–1.0 mmol/l) due to fecal loss. Severe hypomagnesaemia interferes with the parathyroid calcium-sensing receptor [3], resulting in relative hypoparathyroidism, i.e. parathyroid hormone secretion is insufficient to maintain normal serum calcium levels. Because of the presence of Trousseau sign, calcium and magnesium supplementation was started immediately. As a result calcium and magnesium levels normalized and parathyroid hormone levels increased to 17.0 pmol/l. After treatment with metronidazole, diarrhea ceased. This case shows how Trousseau sign could be used to verify deviant calcium levels in clinical practice. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ejim.2016.12.007. Conflict of interest/disclosures None. References [1] Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336(7656):1298–302. [2] Urbano FL. Signs of hypocalcemia: Chvostek's and Trousseau's signs. Wayne, PA: Turner White Communications Inc.; 2000Hospital Physician. [3] Shoback DM, Bilezikian JP, Costa AG, Dempster D, Dralle H, Khan AA, et al. Presentation of hypoparathyroidism: etiologies and clinical features. J Clin Endocrinol Metab 2016;101(6):2300–12.
2. What is your diagnosis? 2.1. Diagnosis As shown in the video, flection of the wrist, extension of the interphalangeal joints and adduction of the fingers occurred. This phenomenon is known as Trousseau sign, which is typical for hypocalcaemia [1]. The described muscle contraction is the result of increased neural excitability due to hypocalcaemia, enforced by ischemia due to the inflated blood pressure cuff and can be found in 94% of all patients with hypocalcaemia [2]. In this case, laboratory tests indeed confirmed a very low total calcium level of 1.36 mmol/l (reference value 2.10–2.55 mmol/l). Serum ⁎ Corresponding author at: Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands. E-mail address: [email protected] (D.J.L. van Twist).
http://dx.doi.org/10.1016/j.ejim.2016.12.007 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Gingele AJ, van Twist DJL, A 76-year-old woman with electrolyte abnormalities, Eur J Intern Med (2016), http:// dx.doi.org/10.1016/j.ejim.2016.12.007