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| '''For patient information, click [[Hypocalcemia (patient information)|here]]'''
| | __NOTOC__ |
| | {{Hypocalcemia}} |
| | {{CMG}}; {{AE}} {{VKG}}{{Vbe}} |
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| {{DiseaseDisorder infobox | | | {{SK}} hypocalcemia; low serum calcium level; hypocalcaemia |
| Name = Hypocalcemia |
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| ICD10 = {{ICD10|E|83|5|e|70}} |
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| ICD9 = {{ICD9|275.41}} |
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| ICDO = |
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| Image = Ca-TableImage.png |
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| Caption = [[Calcium]] |
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| OMIM = |
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| OMIM_mult = |
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| MedlinePlus = |
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| DiseasesDB = 6412 |
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| MeshID = D006996 |
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| }}
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| {{SI}}
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| {{CMG}}
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| ==Overview== | | {| class="infobox" style="float: right;" |
| | | style="vertical-align: middle; padding: 5px;" align=center | [[File:Siren.gif|30px|link=Hypocalcemia resident survival guide]] |
| | | style="vertical-align: middle; padding: 5px;" align=center | [[Hypocalcemia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
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| '''Hypocalcemia''' is the presence of low [[blood plasma|serum]] [[calcium]] levels in the [[blood]], usually taken as less than 3.5 mmol/L or 8.8 mg/dl or an [[ion]]ized calcium level of less than 1.1 mmol/L (4.5 mg/dL). It is a type of [[electrolyte disturbance]]. In the blood, about half of all calcium is bound to proteins such as [[serum albumin]], but it is the unbound, or ''ionized'', calcium that the body regulates. If a person has abnormal levels of blood proteins then the plasma calcium may be inaccurate. The ionized calcium level is considered more clinically accurate in this case.
| | ==[[Hypocalcemia overview|Overview]]== |
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| [[Calcium]] is the most abundant mineral in the body. 99% of the body's calcium is stored in bone. Calcium is found in plasma and is either protein-bound or ionized and readily available. | | ==[[Hypocalcemia historical perspective|Historical Perspective]]== |
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| ==Alkalosis== | | ==[[Hypocalcemia classification|Classification]]== |
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| As [[blood plasma]] hydrogen ion concentration decreases, caused by respiratory or metabolic [[alkalosis]], freely ionized calcium concentration decreases. This freely ionized calcium is the biologically active component of blood calcium. Since a portion of both hydrogen ions and calcium are bound to serum [[albumin]], when blood becomes alkalotic, bound hydrogen ions dissociate from albumin, freeing up the albumin to bind with more calcium and thereby decreasing the freely ionized portion of total serum calcium. For every 0.1 increase in pH, ionized calcium decreases by about 0.05 mmol/l.
| | ==[[Hypocalcemia pathophysiology|Pathophysiology]]== |
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| This hypocalcemia related to alkalosis is partially responsible for the cerebral [[vasoconstriction]] that causes the [[lightheadedness]], [[fainting]], and [[parasthesia]] often seen with [[hyperventilation]].
| | ==[[Hypocalcemia causes|Causes]]== |
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| ==Causes== | | ==[[Hypocalcemia differential diagnosis|Differentiating Hypocalcemia from other Diseases]]== |
| Hypocalcemia can be the consequence of multiple disease processes, some of which will be mentioned in the following discussion. The most common cause is the inability to mobilize calcium from bone which is primarily induced by decreased levels of the parathyroid hormone (PTH) due to derangement of the parathyroid gland function (ie, the gland responsible of calcium homeostasis) or vitamin D deficiency.
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| * Hypoparathyroidism: It signifies diminished activity of the parathyroid gland due to multiple reasons: autoimmune destruction (included in the polyglandular autoimmune syndrome type I), resection of the glands as a possible complication of total thyroidectomy or genetic diseases affecting the gland's function. A second entity that should be mentioned is pseudohypoparathyroidism which is characterized by normal gland function but inability of the PTH-target organs (bone and kidney) to respond to PTH. Patients present with hypocalcemia but high PTH levels.
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| ==Complete Differential Diagnosis of the Causes of Hypocalcemia== | | ==[[Hypocalcemia epidemiology and demographics|Epidemiology and Demographics]]== |
| (In alphabetical order)
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| * Absent active [[vitamin D]]
| | ==[[Hypocalcemia risk factors|Risk Factors]]== |
| * Absent [[parathyroid hormone]] (PTH)
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| * Acquired [[hypoparathyroidism]]
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| * [[Acute pancreatitis]]
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| * [[Acute renal failure]]
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| * [[Adrenocortical hyperplasia]]
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| * [[Alcohol abuse]]
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| * [[Alkalosis]]
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| * [[Anticonvulsant]] therapy
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| * [[Breast cancer]]
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| * [[Bronchial cancer]]
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| * [[Burns]]
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| * [[Chelation]] therapy
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| * [[Chronic renal failure]]
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| * [[Cirrhosis]]
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| * Decreased dietary intake
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| * Decreased [[ultraviolet]]/sun ([[vitamin D deficiency]])
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| *Defective [[Vitamin D]] metabolism
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| * Deficient [[PTH]]
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| * [[DiGeorge's syndrome]]
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| * [[Diuretic]] therapy
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| * [[Drugs]]
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| * [[Eating disorders]]
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| * [[Enemas]], [[laxative]]s
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| * Enhanced [[bone]] formation
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| * Excessive secretion of calcitonin
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| * Exposure to [[hydrofluoric acid]]
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| * [[Familial hypocalcemia]]
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| * Following [[thyroidectomy]]
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| * Hereditary [[hypoparathyroidism]]
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| * "Hungry Bone Syndrome" following [[parathyroidectomy]],
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| * [[Hyperphosphatemia]]
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| * [[Hyperventilation]].
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| * [[Hypoalbuminemia]] (pseudohypocalcemia)
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| * [[Hypomagnesemia]]
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| * [[Hypoparathyroidism]]
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| * [[Hypoproteinemia]]
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| * Increased [[diuresis]] with physiologic saline solution
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| * Intestinal [[malabsorption]]
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| * Intravenous phosphate administration
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| * Kidney diseases with reduced formation of activated [[vitamin D]]
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| * [[Magnesium]] depletion
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| * [[Magnesium]] over supplementation
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| * [[Malabsorption]]
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| * Mal[[digestion]]
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| * [[Medullary carcinoma of the thyroid]]
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| * Neonatal [[tetany]]
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| * [[Nephrotic syndrome]]
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| * [[Osteitis fibrosa]] following [[parathyroidectomy]]
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| * Osteoblastic metastases
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| * [[Osteoporosis]]
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| * [[Pancreatitis]]
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| * Polyglandular [[autoimmune]] syndrome
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| * Postoperative
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| * Prolonged use of medications/laxatives containing [[magnesium]]
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| * [[Pseudohypoparathyroidism]]
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| * [[Renal failure]]
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| * [[Rhabdomyolysis]]
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| * [[Rickets]]
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| * [[Sepsis]]
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| * [[Septic shock]]
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| * Severe acute [[hyperphosphatemia]]
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| * [[Short bowel syndrome]]
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| * [[Steroid]] therapy
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| * [[Thyroid cancer]]
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| * [[Transfusion]] of citrated blood
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| * [[Tumor lysis syndrome]]
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| * [[Vitamin D deficiency]]
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| * Vitamin-D dependent [[rickets]], type I
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| ===Complete Differential Diagnosis of the Causes of Hypocalcemia=== | | ==[[Hypocalcemia screening|Screening]]== |
| (By organ system)
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| {|style="width:80%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| [[Alcohol abuse]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| [[Anticonvulsant]] therapy, [[Chelation]] therapy, [[Diuretic]] therapy, [[Drugs]], [[Enemas]], [[laxative]]s, [[Steroid]] therapy
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| Absent [[parathyroid hormone]] (PTH), Acquired [[hypoparathyroidism]], [[Adrenocortical hyperplasia]], Deficient [[PTH]], Excessive secretion of calcitonin, [[Familial hypocalcemia]], Following [[thyroidectomy]], Hereditary [[hypoparathyroidism]], "Hungry Bone Syndrome" following [[parathyroidectomy]], [[Hypoparathyroidism]], [[Hypoproteinemia]], [[Medullary carcinoma of the thyroid]], [[Osteitis fibrosa]] following [[parathyroidectomy]], [[Osteoporosis]], [[Pseudohypoparathyroidism]], [[Thyroid cancer]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| Decreased [[ultraviolet]]/sun ([[vitamin D deficiency]]), Defective [[Vitamin D]] metabolism, Exposure to [[hydrofluoric acid]]
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| [[Acute pancreatitis]], [[Cirrhosis]], Decreased dietary intake, [[Eating disorders]], [[Enemas]], [[laxative]]s, Intestinal [[malabsorption]], [[Malabsorption]], Mal[[digestion]], [[Pancreatitis]], [[Rickets]], [[Short bowel syndrome]], Vitamin-D dependent [[rickets]], type I
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| [[DiGeorge's Syndrome]], [[Familial hypocalcemia]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| [[Hypoalbuminemia]] (pseudohypocalcemia), [[Transfusion]] of citrated blood, [[Tumor lysis syndrome]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| [[Sepsis]], [[Septic shock]]
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| Enhanced [[bone]] formation, Excessive secretion of calcitonin, Neonatal [[tetany]], [[Osteitis fibrosa]] following [[parathyroidectomy]], [[Osteoporosis]], [[Rickets]], Vitamin-D dependent [[rickets]], type I
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| Absent active [[vitamin D]], Decreased dietary intake, [[Hyperphosphatemia]], Intestinal [[malabsorption]], Intravenous phosphate administration, [[Magnesium]] depletion, [[Rickets]], [[Vitamin D deficiency]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| [[Breast cancer]]
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| [[Breast cancer]], [[Bronchial cancer]], [[Medullary carcinoma of the thyroid]], Osteoblastic metastases, [[Thyroid cancer]], [[Tumor lysis syndrome]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| [[Magnesium]] over supplementation, Prolonged use of medications/laxatives containing [[magnesium]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| [[Eating disorders]]
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| [[Bronchial cancer]], [[Hyperventilation]]
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| [[Acute renal failure]], [[Alkalosis]], [[Chronic renal failure]], [[Hypomagnesemia]], [[Hypoproteinemia]], Increased [[diuresis]] with physiologic saline solution, Intravenous phosphate administration, Kidney diseases with reduced formation of activated [[vitamin D]], [[Magnesium]] depletion, [[Magnesium]] over supplementation, [[Nephrotic syndrome]], [[Renal failure]], [[Rhabdomyolysis]], Severe acute [[hyperphosphatemia]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| [[DiGeorge's Syndrome]], [[Osteitis fibrosa]] following [[parathyroidectomy]], Polyglandular [[autoimmune]] syndrome
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| [[Burns]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| [[Acute renal failure]], [[Chronic renal failure]], [[Hypoproteinemia]], [[Renal failure]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"|Postoperative, [[Transfusion]] of citrated blood
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| |-
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| |}
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| == Diagnosis == | | ==[[Hypocalcemia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| === History and Symptoms === | | ==Diagnosis== |
| * [[Fatigue]]
| | [[Hypocalcemia history and symptoms|History and Symptoms]] | [[Hypocalcemia physical examination|Physical Examination]] | [[Hypocalcemia laboratory findings|Laboratory Findings]] | [[Hypocalcemia electrocardiogram|Electrocardiogram]] | [[Hypocalcemia x ray|X Ray]] | [[Hypocalcemia CT|CT]] | [[Hypocalcemia MRI|MRI]] | [[Hypocalcemia echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Hypocalcemia other imaging findings|Other Imaging Findings]] | [[Hypocalcemia other diagnostic studies|Other Diagnostic Studies]] |
| * [[Weakness]]
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| * [[Muscle cramp]]ing and spasm
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| * [[Nausea]] and [[vomiting]]
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| * [[Abdominal pain]]
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| * [[Depression]]
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| * [[Irritability]]
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| * [[Delirium]]
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| * [[Psychosis]]
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| * [[Seizures]] (with severe hypocalcemia)
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| * [[Perioral]] tingling and [[parasthesia]], 'pins and needles' sensation over the extremities of hands and feet. This is the earliest symptom of hypocalcemia.
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| ==Signs== | | ==Treatment== |
| * [[Tetany (medical sign)|Tetany]], carpopedal spasm are seen.
| | [[Hypocalcemia medical therapy|Medical Therapy]] | [[Hypocalcemia surgery|Surgery]] | [[Hypocalcemia primary prevention|Primary Prevention]] | [[Hypocalcemia secondary prevention|Secondary Prevention]] | [[Hypocalcemia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Hypocalcemia future or investigational therapies|Future or Investigational Therapies]] |
| * Latent tetany
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| ** [[Trousseau sign of latent tetany]] (eliciting carpal spasm by inflating the [[blood pressure]] cuff and maintaining the cuff pressure above [[systolic]])
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| ** [[Chvostek's sign]] (tapping of the inferior portion of the [[zygoma]] will produce facial spasms)
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| * Tendon reflexes are hyperactive
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| * Life threatening complications
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| ** [[Laryngospasm]]
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| ** [[Cardiac arrhythmia]]s
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| ==Clinical Features Associated with Hypocalcemia== | | ==Case Studies== |
| | [[Hypocalcemia case study one|Case #1]] |
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| * [[Abdominal pain]]
| | ==Related Chapters== |
| * [[Alopecia]]
| | * [[Calcium metabolism|Calcium Metabolism]] |
| * [[Anxiety]]
| | * [[Hypercalcaemia]] |
| * [[Atopic eczema]]
| | * [[Calcium deficiency (plant disorder)|Calcium Deficiency (Plant Disorder)]] |
| * [[Biliary colic]]
| | * [[Hypomagnesemia with secondary hypocalcemia|Hypomagnesemia with Secondary Hypocalcemia]] |
| * [[Brittle nails]]
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| * [[Bronchial spasm]]
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| * Calcification of cerebral cortex or cerebellum
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| * [[Cardiomyopathy]]
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| * [[Choreoathetosis]]
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| * [[Chvostek's sign]]
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| * Coarse hair
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| * [[Confusion]]
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| * [[Congestive heart failure]]
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| * Delayed tooth eruption
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| * Disorientation
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| * [[Dry skin]]
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| * [[Dysphagia]]
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| * [[Dyspnea]]
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| * Dystonic spasms
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| * Enamel hypoplasia
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| * Exfoliative dermatitis
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| * Extrapyramidal signs due to calcification of basal ganglia
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| * [[Fatigue]]
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| * Impaired intellectual ability
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| * Impetigo herpetiformis
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| * Increased dental caries
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| * Increased intracranial pressure
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| * [[Irritability]]
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| * [[Laryngeal spasm]]
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| * [[Muscle cramp]]s
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| * Nonspecific EEG changes
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| * [[Papilledema]]
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| * [[Paresthesia]]
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| * [[Parkinsonism]]
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| * Personality disturbances
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| * [[Polymyositis]]
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| * Prolonged QT interval in EKG
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| * [[Psoriasis]]
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| * [[Psychoneurosis]]
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| * [[Psychosis]]
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| * [[Seizure]]s (focal, petit mal, grand mal)
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| * Shortened premolar roots
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| * Subcapsular cataracts
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| * [[Tetany]]
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| * Thickened lamina dura
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| * [[Trousseau's sign]]
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| * [[Wheezing]]
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| == Laboratory Findings == | |
| Suggested initial laboratory studies include the following:
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| * Serum calcium
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| * Ionized calcium
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| * [[Complete blood count]] | |
| * Blood urea nitrogen (BUN)/creatinine
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| * [[Magnesium]]
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| * [[Albumin]]
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| * [[Phosphorus]]
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| * Amylase/lipase
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| Additional laboratory studies to be obtained as part of a more complete evaluation include the following:
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| * [[Vitamin D]] levels | |
| * [[Parathyroid hormone]] | |
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| ==Electrocardiographic Findings==
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| # Prolongation of the [[QTc interval]] is the major EKG finding
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| # There is a lengthening of the interval between the end of the [[QRS]] and the beginning of the [[T wave]] (i.e. [[ST-segment]] lengthening).
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| ==EKG examples==
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| [[image:Hypocalcemia_ProlongedQT.jpg|thumb|left|300px|Prolonged QTc interval due to hypocalcemia]]
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| <br clear="left"/>
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| ==Management==
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| * Two [[ampoule]]s of [[intravenous]] [[calcium gluconate]] 10% is given slowly in a period of 10 minutes, or if the hypocalcemia is severe, [[calcium chloride]] is given instead. | |
| * Maintenance doses of both calcium and vitamin-D (often as 1,25-(OH)<sub>2</sub>-D<sub>3</sub>, i.e. [[calcitriol]])) are often necessary to prevent further decline.
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| ==References== | | ==References== |
| {{Reflist|2}} | | {{reflist|2}} |
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| ==Related chapters==
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| * [[Calcium metabolism]]
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| * [[Hypercalcaemia]]
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| * [[Calcium deficiency (plant disorder)]]
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| * [[Hypomagnesemia with secondary hypocalcemia]]
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| ==Resources==
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| * [http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/hypocalcemia/ Cleveland Clinic] Hypocalcemia chapter Online Medical Reference
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| * [http://www.endotext.org/parathyroid/parathyroid7/parathyroid7.htm Endotext]
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| * [http://www.chestjournal.org/cgi/content/full/119/2/668-a EKG abnormalities associated with hypocalcemia]
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| * [http://ndt.oxfordjournals.org/cgi/reprint/20/12/2855.pdf Seizures due to hypocalcaemia worsened by shifting towards alkalosis by bicarbonate therapy]
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| * [http://www-isu.indstate.edu/mary/lytenote.htm Electrolytes]
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| {{Electrocardiography}} | | {{Electrocardiography}} |
| {{SIB}}
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| [[Category:Disease]] | | [[Category:Disease]] |
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| [[Category:Endocrinology]] | | [[Category:Endocrinology]] |
| [[Category:Nephrology]] | | [[Category:Nephrology]] |
| [[Category:Emergency medicine]] | | [[Category:Needs content]] |
| [[Category:Blood tests]]
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