Hypocalcemia Clinical Presentation

  • Author: Manish Suneja, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Oct 27, 2011
 

History

In neonates, hypocalcemia is more likely to occur in infants born of diabetic or preeclamptic mothers. Hypocalcemia also may occur in infants born to mothers with hyperparathyroidism.

Clinically evident hypocalcemia generally presents in milder forms and is usually the result of a chronic disease state. In emergency department patients, chronic or subacute complaints secondary to mild or moderate hypocalcemia are more likely to be a chief complaint than severe symptomatic hypocalcemia.

Once laboratory results demonstrate hypocalcemia, the first question is whether the hypocalcemia is true—that is, whether it is representative of a decrease in ionized calcium. The presence of chronic diarrhea or intestinal disease (eg, Crohn disease, sprue, chronic pancreatitis) suggests the possibility of hypocalcemia due to malabsorption of calcium and/or vitamin D.

The patient's past medical history should be explored for pancreatitis, anxiety disorders, renal or liver failure, gastrointestinal disorders, and hyperthyroidism or hyperparathyroidism. Previous neck surgery suggests hypoparathyroidism; a history of seizures suggests hypocalcemia secondary to anticonvulsants. The patient may have a recent history of thyroid, parathyroid, or bowel surgeries or recent neck trauma.

The length of time that a disorder is present is an important clue. Hypoparathyroidism and pseudohypoparathyroidism are lifelong disorders. Instead, acute transient hypocalcemia may be associated with acute gastrointestinal illness, nutritional deficiency, or acute or chronic renal failure.

In an elderly patient, a nutritional deficiency may be associated with a low intake of vitamin D. A history of alcoholism can help diagnose hypocalcemia due to magnesium deficiency, malabsorption, or chronic pancreatitis.

Inquire about recent use of drugs associated with hypocalcemia, including the following:

  • Radiocontrast
  • Estrogen
  • Loop diuretics
  • Bisphosphonates
  • Calcium supplements
  • Antibiotics
  • Antiepileptic drugs
  • Cinacalcet

Other considerations in the history include the following:

  • Family history of hypocalcemia
  • Low-calcium diet
  • Lack of sun exposure

Acute hypocalcemia may lead to syncope, congestive heart failure (CHF), and angina due to the multiple cardiovascular effects.[29] Neuromuscular and neurologic symptoms may also occur.[30]

Neuromuscular symptoms include the following[31] :

  • Numbness and tingling sensations in the perioral area or in the fingers and toes
  • Muscle cramps, particularly in the back and lower extremities; may progress to carpopedal spasm (ie, tetany)
  • Wheezing; may develop from bronchospasm
  • Dysphagia
  • Voice changes (due to laryngospasm)

Neurologic symptoms of hypocalcemia include the following[32] :

  • Irritability, impaired intellectual capacity, depression, and personality changes
  • Fatigue
  • Seizures (eg, grand mal, petit mal, focal)
  • Other uncontrolled movements

Chronic hypocalcemia may produce the following dermatologic manifestations:

  • Coarse hair
  • Brittle nails
  • Psoriasis
  • Dry skin
  • Chronic pruritus
  • Poor dentition
  • Cataracts
Next

Physical Examination

Neuromuscular and cardiovascular findings predominate. Neural hyperexcitability due to acute hypocalcemia causes smooth and skeletal muscle contractions. In addition, patients may appear confused or disoriented and may exhibit signs of dementia or overt psychosis. Irritability, confusion, hallucinations, dementia, extrapyramidal manifestations, and seizures may occur.

On head and neck examination, the hair may appear coarse, and alopecia may be present. Signs of recent trauma or of surgery of the neck (eg, scars over the thyroid region) should be noted. Perioral anesthesia may be present, and adults with chronic (since childhood) hypocalcemia may be at an increased risk for dental caries and enamel hypoplasia. On eye examination, subcapsular cataracts or papilledema may be seen.

On respiratory examination, inspiratory or expiratory wheezes may be present. Smooth muscle contraction may lead to laryngeal stridor, dysphagia, and bronchospasm. On cardiac examination, bradycardia, tachycardia, S3, and signs of heart failure may be present.[33]

Dry skin or patches of psoriasis and eczema may be present, particularly in patients with chronic hypocalcemia. Excoriations as a result of pruritus may be noted. Test for Chvostek sign by tapping the skin over the facial nerve about 2 cm anterior to the external auditory meatus. Ipsilateral contraction of the facial muscles is a positive sign. Depending on the calcium level, a graded response will occur: twitching first at the angle of the mouth, then by the nose, the eye, and the facial muscles. Up to 10% of the population will have a positive Chvostek sign in the absence of hypocalcemia; thus, this test, while suggestive, is not diagnostic of hypocalcemia.

Test for the Trousseau sign by placing a blood pressure cuff on the patient’s arm and inflating to 20 mm Hg above systolic blood pressure for 3-5 minutes. This increases the irritability of the nerves, and a flexion of the wrist and metacarpal phalangeal joints can be observed with extension of the interphalangeal joints and adduction of the thumb (carpal spasm). The Trousseau sign is more specific than the Chvostek sign but has incomplete sensitivity.

Movement abnormalitiesassociated with hypocalcemia include the following:

  • Choreoathetosis[34]
  • Dystonic spasm
  • Parkinsonism
  • Hemiballism

Peripheral nervous system findings include tetany, focal numbness, and muscle spasms. Smooth muscle contraction causes biliary colic, intestinal colic, and dysphagia. Seizures often occur in individuals with preexistent epileptic foci when the excitation threshold is lowered.

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Contributor Information and Disclosures
Author

Manish Suneja, MD  Assistant Professor, Department of Internal Medicine, Division of Nephrology, University of Iowa Hospitals and Clinics

Manish Suneja, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Heather A Muster  MD, MS, Medical Director

Heather A Muster is a member of the following medical societies: American College of Physicians, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Minnesota Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Christopher B Beach, MD, FACEP, FAAEM Associate Professor and Vice Chair of Emergency Medicine, Department of Emergency Medicine, Associate Professor of Institute for Healthcare Studies, Institute for Patient Safety, Feinberg School of Medicine, Northwestern University

Christopher B Beach, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eleanor Lederer, MD Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Genzyme Honoraria Speaking and teaching

Alfredo A Pegoraro, MD Consulting Staff, Nephrology Associates

Alfredo A Pegoraro, MD is a member of the following medical societies: American Medical Assocation, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Electrocardiogram (ECG) findings in severe hypocalcemia.
 
 
 
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