Primary hypoparathyroidism accompanied by rhabdomyolysis induced by infection: A case report

BACKGROUND Primary hypoparathyroidism(HPT)is rarely seen in the clinic,and it can be combined with rhabdomyolysis.There are few reports about this phenomenon.Therefore,it is significant to explore the etiology that is conducive to early diagnosis,timely treatment,and preventing the recurrence.CASE SUMMARY A 63-year-old man was admitted to our hospital with a severe upper respiratory tract infection and progressing decreased myodynamia of the lower limbs.Blood tests showed creatine kinase>32000 U/L,creatinine 207.8μmol/L,calcium 1.28 mmol/L,myoglobin 558.7 ng/mL,and parathyroid hormone 0 pg/mL.He was diagnosed with primary HPT with rhabdomyolysis,and severe upper respiratory tract infection was considered to be the initial trigger.He responded well to supplementation of intravenous calcium gluconate and oral calcium as well as bedside hemodialysis,fluid hydration,infection control,protecting the liver,etc.Creatine kinase,myoglobin,and serum calcium returned to normal,and muscle strength improved significantly.Symptoms improved after symptomatic treatment.CONCLUSION Severe infection should be prevented,which is the key cause of rhabdomyolysis in patients with HPT.

Hypoparathyroidism with Fahr’s syndrome: A case report and review of the literature

BACKGROUND Hypoparathyroidism with basal ganglia calcification is clinically rare.Here,we report a case of Fahr’s syndrome due to hypoparathyroidism and review the literature in terms of etiology,clinical manifestation,diagnosis,and treatment.CASE SUMMARY A 62-year-old man experienced repeated twitching of both hands in recent 10 years.On July 28,2017,the patient was admitted to our hospital due to slow response and speech difficulties.On medical examinations,he had a positive Chvostek sign,while no Albright’s hereditary osteodystrophy signs or history of neck surgery or radiation,and his family members had no similar medical history.Laboratory examinations revealed hypocalcemia,hyperphosphatemia,and low parathyroid hormone(PTH)levels.Computed tomography revealed basal ganglia calcification.Based on these investigations,a diagnosis of Fahr’s syndrome due to hypoparathyroidism was suggested.After receiving intravenous calcium gluconate to relieve symptoms,the patient continued to take oral calcium carbonate and calcitriol for treatment.CONCLUSION The possibility of hypoparathyroidism should be considered in patients with chronic hypocalcemia,recurrent tetany,and even neuropsychiatric symptoms.Hypoparathyroidism is a common cause of basal ganglia calcification.Therefore,it is recommended that blood calcium,phosphorus,and PTH levels should be measured in all individuals with basal ganglia calcification to exclude hypoparathyroidism.

THE CHANGES OF BONE MINERAL DENSITY IN PATIENTS WITH HYPOPARATHYROIDISM

This study observed the changes of BMD, serum calcium, bone Gla protein and calcitonin of patients with hypoparathyroidism controlled by age and sex matched healthy persons. It was found that BMD was 10% greater in hypoparathyroidism patients than in controls, but the difference was not statistically significant. Serum BGP was significantly lower in hypoparathyroidism patients than in controls (P<0. 02). We postulate that PTH deficiency and long term treatment with calcium and vitamin D for hypoparathyroidism appear to be main mediator of this increased bone mass,and that hone mass is not affected by endogenous calcitonin.

Treatment of hypocalcemia caused by hypoparathyroidism or pseudohypoparathyroidism with domestic-made calcitrioh a prospective and self-controlled clinical trial

Background Parathyroid hormone deficiency or resistance may cause hypocalcemia with related symptoms and signs. Lifelong treatment of calcium combined with vitamin D or its metabolites is always necessary for these patients. Here we reported a prospective and open-label trial to investigate the efficacy and safety of domestic-made calcitriol in treatment of hypocalcemia caused by hypoparathyroidism or pseudohypoparathyroidism. Methods Twenty-four patients with confirmed hypoparathyroidism or pseudohypoparathyroidism aged （36.5±11.0） years old were studied. Among them, 16 patients had idiopathic hypoparathyroidism, 2 had pseudohypoparathyroidism and 6 had hypoparathyroidism secondary to cervical surgery. Serum calcium levels were lower than 1.88 mmol/L. Oral calcitriol was administered twice or three times with elemental calcium 1.2 g per day. All patients were followed every 4 weeks throughout the 12-week period. Dose adjustments of calcitriol were based on serum and urinary calcium levels and symptoms of hypocalcemia. Results Twenty patients were included by the end of this study. Muscular weakness, cramps, extremity paresthesia, Chovestek＇s sign and Trousseau＇s sign were relieved in 76.9%, 100%, 94.4%, 93.3% and 78.9% of patients, respectively. Serum calcium, plasma ionized calcium and serum phosphorus levels were （1.54±0.25） mmol/L, （0.64±0.10） mmol/L and （2.00±0,46） mmol/L at baseline, and reached （2.20±0.20） mmol/L, （0.95±0.06） mmol/L and （1.68±0.25） mmol/L （P 〈0.01） at the 12th week of treatment, respectively. Eighty percent of patients were assessed as effective and 20% as partly effective. Three, four and eight patients had hypercalciuria at the 4th, 8th and 12th week of treatment, respectively, which were reduced by thiazide diuretics. The final dose of calcitriol was （1.09±0.50） ug/d. Conclusions Calcitriol combined with calcium can be used in treatment of hypocalcemia caused by hypoparathyroidism or pseudohypoparathyroidism effectively and safely. Serum and urinary calcium levels should be monitored during the course of the therapy.

Advances in the application of auxiliary imaging techniques in parathyroid diseases

Hypoparathyroidism is one of the main complications after total thyroidectomy,severely affecting patients’quality of life.How to effectively protect parathyroid function after surgery and reduce the incidence of hypoparathyroidism has always been a key research area in thyroid surgery.Therefore,precise localization of parathyroid glands during surgery,effective imaging,and accurate surgical resection have become hot topics of concern for thyroid surgeons.In response to this clinical phenomenon,this study compared several different imaging methods for parathyroid surgery,including nanocarbon,indocyanine green,near-infrared imaging techniques,and technetium-99m methoxyisobutylisonitrile combined with gamma probe imaging technology.The advantages and disadvantages of each method were analyzed,providing scientific recommendations for future parathyroid imaging.In recent years,some related basic and clinical research has also been conducted in thyroid surgery.This article reviewed relevant literature and provided an overview of the practical application progress of various imaging techniques in parathyroid surgery.

A Novel De novo GATA-binding Protein 3 Mutation in a Patient with Hypoparathyroidism, Sensorineural Deafness, and Renal Dysplasia Syndrome

INTRODUCTION Hypoparathyroidism, sensorineural deafness, and renal dysplasia （HDR） syndrome, also called Barakat syndrome, is an autosomal dominant genetic disease caused by haploinsufficiency of the GATA-binding protein 3 （GATA3） gene located on the 10pl 5 chromosome.

Successful xenotransplantation of microencapsulated newborn pig parathyroid cells in the treatment of hypoparathyroidism in rats

Objective To study the effect of xenotransplantation with pig parathyroid cells,which was prepared using cell microencapsulation technique,on the treatment of hypoparathyroidism in rats without immunosuppressor. Methods Parathyroid cells were isolated from 10 healthy newborn pigs and encapsulated in alginate-polylysine-alginate (APA) membranes. Thirty-two aparathyroid Wistar rats were randomly allocated to microcapsule,non-microcapsule,empty microcapsule,and control groups. Each rat was injected intraperitoneally with encapsulated porcine parathyroid cells,free porcine parathyroid cells,empty capsules or 0.9% NaCl,respectively. Total serum calcium and parathyroid hormone levels were monitored continuously for 40 weeks. And then,the transplant beds were retrieved and subjected to morphologic and electron microscopic examination. Results In those animals xenotransplanted with microencapsulated porcine parathyroid cells,the calcium and PTH levels were consistently within the normal range during the 40 weeks. In contrast,no therapeutic effects were observed in rats in the non-microcapsule group. Furthermore,neither empty capsules nor 0.9% NaCl were shown to have any effect on the recipient’s serum calcium or PTH levels. After 40 weeks,electron microscopic examination demonstrated that the parathyroid cells within the microcapsules had survived well in vivo . Conclusions Xenotransplantation of microencapsulated newborn pig parathyroid cells can successfully treat hypoparathyroidism in rats without using immunosuppressive drugs. The results of this study show the possible clinical use of microencapsulated porcine parathyroid cells.

Liver transplantation for hypoparathyroidism secondary to Wilson's disease

To the Editor: A 19-year-old man was admitted to the hospital presenting with “skin and sclera yellow staining for 18 years, accompanied by growth retardation.” The patient developed scleral yellowing at 4 months of age, at which time he was diagnosed as having Wilson's disease (WD) and received symptomatic treatment for liver protection. At 9 years of age the patient developed a pale nail bed, clubbing of the fingers and toes, and accompanying growth retardation. A spontaneous fracture of the right upper limb and left pubic bone occurred at 16 years of age. At 17 years of age the patient developed neuropsychiatric symptoms consisting of fatigue, personality changes, mental retardation, numbness, epileptic seizures, and constipation. He required daily glycerin to assist with defecation. At 5 months prior to admission, obvious sternal malformations and anterior sternal processes were present. Family history revealed that his parents were close relatives (cousin-sister relationship) and the patient's cousin died as a result of WD at age of 12 years. The patient's younger brother was 3 years old and also had a history of WD.

Hypoparathyroidism presenting with late onset seizures - a report of two cases from rural India

Hypoparathyroidism leading to hypocalcaemia is an important treatable cause of recurrent seizures. Neurological manifestations due to hypoparathyroidism include: seizures, paresthesia, depression, psychosis, extra pyramidal symptoms, and features of raised intracranial pressure. Seizures may be the presenting symptoms preceding other signs of hypocalcaemia. Primary hypoparathyroidism presenting for the first time as seizures in the elderly is quite rare. Here we report two cases of hypoparathyroidism presenting with seizures in the elderly as the sole manifestation of hypocalcaemia. The goal of this report is to seek attention to such an uncommon reversible treatable cause of seizures and to consider hypoparathyroidism in the work up of these patients.

A genomic study of adult-onset idiopathic hypoparathyroidism in Chinese by targeted next-generation sequencing

Objective To screen gene mutation in adult-onset hypoparathyroidism in Chinese through the targeted nextgeneration sequencing(NGS).Methods We recruited 17patients with adult-onset hypoparathyroidism who were regularly followed or newly diagnosed at our centre during the past one year.Nine of them developed hypercalciuria during the treatment with calcium and vitamin D.

Clinical and genetic features of Kenny-Caffey syndrome type 2 with multiple electrolyte disturbances:A case report

BACKGROUND Hypoparathyroidism,which can be sporadic or a component of an inherited syndrome,is the most common cause of hypocalcemia.If hypocalcemia is accompanied by other electrolyte disturbances,such as hypokalemia and hypomagnesemia,then the cause,such as renal tubular disease,should be carefully identified.CASE SUMMARY An 18-year-old female visited our clinic because of short stature and facial deformities,including typical phenotypes,such as low ear position,depression of the nasal bridge,small hands and feet,and loss of dentition.The lab results suggested normal parathyroid hormone but hypocalcemia.In addition,multiple electrolyte disturbances were found,including hypokalemia,hypocalcemia and hypomagnesemia.The physical signs showed a short fourth metatarsal bone of both feet.The X-ray images showed cortical thickening of long bones and narrowing of the medulla of the lumen.Cranial computed tomography indicated calcification in the bilateral basal ganglia.Finally,the genetic investigation showed a de novo heterogenous mutation of“FAM111A”(c.G1706A:p.R569H).Through a review of previously reported cases,the mutation was found to be the most common mutation site in Kenny-Caffey syndrome type 2(KCS2)cases reported thus far(16/23,69.6%).The mutation was slightly more prevalent in females than in males(11/16,68.8%).Except for hypocalcemia,other clinical manifestations are heterogeneous.CONCLUSION As a rare autosomal dominant genetic disease of hypoparathyroidism,the clinical manifestations of KCS2 are atypical and diverse.This girl presented with short stature,facial deformities and skeletal deformities.The laboratory results revealed hypocalcemia as the main electrolyte disturbance.Even though her family members showed normal phenotypes,gene detection was performed to find the mutation of the FAM111A gene and confirmed the diagnosis of KCS2.

Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review

BACKGROUND In recent decades,significant advances have been made in protecting the parathyroid glands and recurrent laryngeal nerves during thyroidectomy.However,reliable and convenient technical means are still lacking.In this study,the reliability,safety and feasibility of near-infrared(NIR)laparoscopyassisted thyroid lobectomy with isthmectomy and prophylactic central lymph node dissection(CLND)were reported.CASE SUMMARY A 63-year-old female patient with a free previous medical history,was admitted to our department due to multiple thyroid nodules.Ultrasonic examination suggested diffuse thyroid changes and one thyroid nodule in the right upper lobe with the largest diameter of 1.5 cm adjacent to the trachea and Breast Imaging Reporting and Data System grade 4B.Imaging examination of the neck showed no obvious enlarged lymph nodes.Fine needle aspiration biopsy suggested a papillary thyroid carcinoma.Combined with thyroid function examination,the patient was diagnosed with papillary thyroid carcinoma and Hashimoto's thyroiditis.Considering the risk of invading the capsule and the patient's extreme anxiety,a right thyroid lobectomy with isthmectomy and prophylactic CLND was planned.No significant abnormalities were found during preoperative examinations,except for an increased thyroid stimulating hormone level.The patient underwent NIR laparoscopy-assisted thyroid lobectomy with isthmectomy and prophylactic CLND.During the operation,two right parathyroid glands(PGs)adjacent to the thyroid gland capsule and the right recurrent laryngeal nerve(RLN)were examined by indocyanine green(ICG)fluorescence using a NIR fluorescence camera,and the PGs and RLN were reliably preserved.Considering the ICG-positive PG,prophylactic CLND was performed.The postoperative parathyroid hormone level was in the normal range and no significant hypocalcemia symptoms were observed.CONCLUSION During NIR laparoscopy-assisted thyroidectomy,ICG fluorescence may aid PG identification and protection.

Identification of the Parathyroid Gland with Vasculature by Intraoperative Carbon Nanoparticles

Background: We aimed to investigate the ability of carbon nanoparticles to identify parathyroid glands with vasculature during thyroid surgery. Material and methods: Totally 42 patients with various thyroid diseases were selected for the prospective research of carbon nanoparticle injection used in thyroidectomy. Another 42 patients without receiving carbon nanoparticle injection were selected as the control group. All cases underwent total or subtotal bilateral thyroidectomy. Before the ligation of the superior and inferior poles of the thyriod lobes, 0.1 mL of a carbon nanoparticle suspension was injected into the two poles. Important tissues such as the recurrent laryngeal nerve, parathyroid gland with blood supply and the inferior thyroid artery were identified and protected. Results: The parathyroid glands with vasculature were not stained and thus remained the primary color in all cases, while abnormal thyroid tissues were stained black. After 5 minutes, thyroid lobes were injected with the carbon nanoparticle suspension and the original color of parathyroid glands was unchanged. Even the parathyroids with blood supply can be identified and protected. The number of parathyroid glands for autotransplantation was one in the test group and six in the control group. At one day after the thyroid surgery, hypocalcemia became detectable in four patients of the test group and in five of the control group. Twenty-four instances of hypoparathyroidism occurred at 1 day after surgery in the control group, while ten instances in the test group. Conclusion: Intraoperatvie carbon nanoparticle suspension injection is an effective and safe technique for guiding thyroid surgery. The carbon nanoparticle suspension plays an important role in identifying the vasculatural parathyroid glands, while protecting the physiologic function of the parathyroid glands during surgery.

Reversible congestive heart failure associated with hypocalcemia:A case report

BACKGROUND Hypoparathyroidism is a rare disease that may occur due to primary or secondary etiologies.The estimated incidence in the United States is 24–37/100000 personyears.Congestive heart failure associated with hypocalcemia due to hypoparathyroidism is an even rarer presentation.CASE SUMMARY Here,we present a 64-year-old woman with congestive heart failure following hypocalcemia.The patient was transferred to our emergency department with complaints of rapidly progressive dyspnea,shortness of breath and heaviness of the chest for 4 d.She had a history of undergoing thyroidectomy and partial tracheotomy 2 years prior due to a malignant thyroid tumor.Muscle spasms had been present 1 year ago,and cataracts were treated with intraocular lens replacement in both eyes.Most tests were within normal ranges,except serum calcium at 1.33 mmol/L(2.20–2.65 mmol/L),ionized calcium at 0.69 mmol/L(1.15–1.29 mmol/L),and parathyroid hormone at<1.0 pg/mL(12–88 pg/mL).Echocardiography revealed an ejection fraction of 28.48%.Cardiac function was quickly reversed by restoring the serum calcium concentration.Significant improvements were noted with an ejection fraction of up to 48.50%at follow-up.CONCLUSION For patients with potential hypocalcemia,monitoring calcium levels and dealing with hypocalcemia in time to avoid serious complications are important.

Bilateral hypocalcaemic cataracts due to idiopathic parathyroid insufficiency:A case report

BACKGROUND Hypoparathyroidism is uncommon,and cataracts secondary to hypoparathyroidism are even rarer.Herein,we report a case of bilateral cataracts following hypoparathyroidism.CASE SUMMARY A 27-year-old man presented to our hospital because of painless and progressive visual impairment of both eyes over two years.He was previously diagnosed with hypocalcemia but did not take calcium supplements regularly.He had no history of anterior neck thyroid surgery.After admission,the biochemical analysis indicated a serum calcium level of 1.21 mmol/L and an intact parathyroid hormone level of 0 pg/mL.Ocular examination revealed bilateral symmetrical opacity of the lens presenting as punctate opacity in the posterior subcapsular cortex together with radial opacity in the peripheral cortex(N1C2P3).Phacoemulsification with an intraocular lens was performed in both eyes sequentially.Postoperatively,the patient had a satisfactory recovery and greatly improved visual acuity.CONCLUSION This patient had hypocalcemia owing to idiopathic parathyroid insufficiency.Hypoparathyroidism may go unnoticed for years but with some latent clinical manifestations,such as bilateral symmetrical posterior subcapsular cataracts.This case report highlights that the cause of hypocalcemia in particularly young patients should be further investigated.Clinicians should be aware of hypoparathyroidism as a cause of bilateral cataracts.Early identification of hypoparathyroidism can save patients from further complications.