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BMJ Case Rep. 2010; 2010: bcr0820092188.
Published online 2010 August 3. doi:  10.1136/bcr.08.2009.2188
PMCID: PMC3029926
Reminder of important clinical lesson

A Moroccan woman with severe electrolyte disorder

Abstract

The case of a Moroccan woman, age 25, who came into the emergency department with clinical tetany, is presented. She had experienced muscle spasms and paresthaesia of the upper limb over the previous few days. She had also experienced major diarrhoea for the previous 3 weeks. Investigations revealed a severe electrolyte disorder.

Background

Electrolyte disorders are often encountered in hospitals and ambulatory care. However, they are often difficult to manage due to the numerous potential causes. Moreover, the presentation is variable and the complete clinical picture is rarely observed. We present a case of tetany caused by multiple circumstances.

Case presentation

A Muslim Moroccan woman, age 25, presented to the emergency department with her husband, a doctor, with muscle spasms and paresthaesia of the upper limb that had persisted over the previous few days. She had also had major diarrhoea for the previous 3 weeks.

The patient, who wore a veil, had given birth a few weeks prior by caesarean section and was still breast feeding. After her pregnancy, she had severe iron deficiency and anaemia that had required several iron injections. In the differential diagnosis, celiac disease was suspected and serological tests gave positive results. A jejunal biopsy was planned to confirm the diagnosis after she terminated breast feeding.

The patient presented with hypotension; her skin was pale and dry, and her eyelids fasciculated. Her forearm, wrist and fingers were flexed and returned to this position after they were manually straightened. The neurological exam showed absent tendon reflex and positive Trousseau (figures 13) and Chvostek signs.

Figure 1
Trousseau sign. A carpopedal spasm occurred a few minutes after inflation of a sphygmomanometer cuff above systolic blood pressure. Occlusion of the brachial artery caused flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers ...
Figure 3
Keep in touch. The spontaneous finger posture enables the patient to hold her mobile phone.
Figure 2
Characteristic hand posture called ‘main d'accoucheur’ (literal translation: the obstetrician hands posture).

Investigations

A laboratory evaluation showed important electrolytic alterations: the patient had severe hypocalcaemia (corrected Ca: 1.41 mmol/litre), severe hypomagnesaemia (total Mg: 0.33 mmol/litre) and severe hypokalaemia (K: 2.4 mmol/litre). Her thromboplastin (TP) time was significantly low (TP: 31%) (normal values for our laboratory: corrected calcium (2.1–2.5 mmol/litre), total magnesium (0.6–1 mmol/litre), potassium (3.5–4.6 mmol/litre), phosphate (0.8–1.4 mmol/litre), thromboplastin time (85% to 125%), 25-OH vitamin D3 (8.4–52.3 ;g/litre), parathormone (10–70 ng/litre)). The patient's phosphate level was normal (1.15 mmol/litre). Further investigations showed low 25-OH vitamin D3 (7.9 ;g/litre) and normal parathormone (60 ng/litre) levels. No bacteria were detected in the stool. An electrocardiogram (ECG) showed a slightly elevated QT interval (0.48 s).

Outcome and follow-up

The patient was hospitalised for further management of electrolyte disorders. The diagnosis of celiac sprue was supported by the intestinal biopsy (figure 4). The tetany resolved after intravenous electrolyte replacement. The patient was able to return home after 4 days of hospitalisation and oral electrolyte supplementation was prescribed. A gluten-free regime was introduced.

Figure 4
An intestinal biopsy confirmed the diagnosis of celiac disease. Subtotal villous atrophy with striking enlargement of crypts. The number of inflammatory cells was significantly elevated in the chorion: numerous lymphocytes and plasmocytes can be observed, ...

Discussion

This case is of interest in understanding the cause of hypocalcaemia that led to the presenting tetany.

First, we note that hypomagnesaemia with secondary hypocalcaemia is a rare condition, most often seen in children.1 Mild hypomagnesaemia induces a resistance to parathormone action, but severe hypomagnesaemia leads to reduced secretion of parathormone. We also note that severe hypermagnesaemia has an important effect on calcium homeostasis due to the suppression of parathormone secretion. In this case, hypomagnesaemia was due to reduced intestinal absorption and was exacerbated by major diarrhoea that occurred during the 3 weeks prior to hospitalisation.

Vitamin D is also important in calcium homeostasis. There are many conditions that can lead to reduced vitamin D2 and secondary hypocalcaemia (scheme 1). In this case, we noted reduced intestinal absorption due to celiac disease. But its also important to keep in mind that hypovitaminosis D may also be due to a lack of exposure to sunshine3 4; this was certainly the case with our patient, who, as a Muslim, always wore a veil outdoors. Finally, we point out that during breast feeding there is an increased vitamin D requirement.3 5

figure bcr.08.2009.2188.f5

There are many conditions that could lead to hypocalcaemia (scheme 1). There may be an increased loss of calcium, as in the case of pancreatitis or osteoblastic bone metastases; it can be the result of a reduction in intake, as in acquired hypoparathyroidism (acquired during surgery, radiotherapy or multiple endocrine neoplasia); or it may be secondary to high dose bisphosphonate treatment.

Celiac disease is most often diagnosed in young children. It is recognised in all ethnic groups with a worldwide prevalence of 1% to 2%.6 The classic symptoms are diarrhoea, anorexia, abdominal pain, weight loss and a failure to thrive. In adults, there are two modes of presentation7: the classic mode, with diarrhoea, abdominal pain and weight loss; and the silent mode, with no symptoms and an atypical presentation (ie, ferriprive anaemia or reduced bone density). Celiac disease rarely presents with a crisis of tetany.810 In our case, the diarrhoea accompanying this tetany was suggestive of celiac disease.11

Learning points

  • Hypomagnesaemia and hypermagnesaemia can lead to hypocalcaemia. The calcium levels cannot be corrected until magnesium has reached a standard level.
  • Women who wear veils are at risk for developing hypovitaminosis D.
  • Tetany is a rare presenting symptom of celiac disease.
  • The association of major diarrhoea and tetany is suggestive of celiac disease.

Acknowledgments

We thank the Institute of Pathology of the University Hospital of Lausanne for its collaboration.

Footnotes

Competing interests None.

Patient consent Patient/guardian consent was obtained for publication.

References

1. Yamamoto T, Kabata H, Yagi R, et al. Primary hypomagnesemia with secondary hypocalcemia. Report of a case and review of the world literature. Magnesium 1985;4:153–64. [PubMed]
2. de Torrente de la Jara G, Pecoud A, Favrat B. Musculoskeletal pain in female asylum seekers and hypovitaminosis D3. BMJ 2004;329:156–7. [PMC free article] [PubMed]
3. Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008;336:1298–302. [PMC free article] [PubMed]
4. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr 2008;87:1080S–6S. [PubMed]
5. Nickkho-Amiry M, Prentice A, Ledi F, et al. Maternal vitamin D status and breast milk concentrations of calcium and phosphorus. Arch Dis Child 2008;93:179. [PubMed]
6. Green PH, Cellier C. Celiac disease. N Engl J Med 2007;357:1731–43. [PubMed]
7. Green PH. The many faces of celiac disease: clinical presentation of celiac disease in the adult population. Gastroenterology 2005;128:S74–8. [PubMed]
8. Barker J, Travers S. Case report: an 11-year-old girl with tetany. Curr Opin Pediatr 2002;14:338–42. [PubMed]
9. Cano Ruiz A, Barbado Hernández FJ, Martín Scapa MA, et al. [Adult celiac disease presenting as tetany]. An Med Interna 1996;13:592–4. [PubMed]
10. Papke J, Raude E. [Recurrent tetany as the first symptom of late manifesting celiac disease]. Med Klin (Munich) 1998;93:619–23. [PubMed]
11. Ukleja A, Scolapio JS. Tetany and profound diarrhea–a diagnostic combination you cannot miss. Am J Gastroenterol 2000;95:1598–9. [PubMed]

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