Hypoparathyroidism in Emergency Medicine Clinical Presentation

Updated: Aug 05, 2015
  • Author: Agnieszka Gliwa, MD; Chief Editor: Erik D Schraga, MD  more...
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Presentation

History

See the list below:

  • A full surgical and family history is essential in cases of suspected hypoparathyroidism.
  • Neuromuscular irritability, arising from hypocalcemia, is the hallmark of the condition. These features can range from mild-to-moderate paresthesias of the extremities or lips to painful muscle cramps. In severe cases, tetany can result in carpopedal spasm, laryngospasm, [13] or generalized seizures. [14] Recurrent laryngospasm should prompt an investigation of underlying hypoparathyroidism. [15]
  • Additionally, severe hypocalcemia can result in neuropsychiatric and cardiovascular abnormalities. Neuropsychiatric manifestations include irritability, anxiety, psychosis, dementia, hallucinations, depression, and confusion. The cardiovascular effects of hypocalcemia are usually bradydysrhythmias or prolongation of the QT interval. Severe hypocalcemia can rarely mimic myocardial infarction. [16]
  • Gastrointestinal complaints may result from hypocalcemia as well. Smooth muscle spasms can result in intestinal and biliary cramping. Several cases of dysphagia have been described in the setting of hypocalcemia. [17]
  • Symptoms are rare unless the ionized calcium level drops below 2.8 mg/dL. [3]
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Physical

The clinical manifestation of hypoparathyroidism is due to hypocalcemia.

  • Head, ears, eyes, nose, and throat signs
    • Surgical/traumatic scars
    • Mucocutaneous candidiasis (in the setting of polyglandular failure type 1 [18] )
  • Neurologic signs
    • Hyperreflexia
    • Tetany
    • Chvostek sign - Chvostek sign has low sensitivity and specificity. Twenty-five percent of healthy persons will have a positive result; 29% of hypocalcemic patients will have a negative result. [3]
    • Trousseau sign (carpal spasm caused by occluding the brachial artery) - Trousseau sign is more reliable. Only 1-4% of healthy persons will have a positive sign; 94% of hypocalcemic persons will have a positive sign. [3]
    • Seizures
    • Altered mental status
  • Cardiovascular signs
    • Heart failure [19, 20, 21]
    • Bradycardia [22]
    • Hypotension not responsive to fluids or pressors [23]
  • Ophthalmologic signs - Cataracts [24]
  • Signs in infants
    • Vomiting
    • Abdominal distention
    • Apneic spells
    • Intermittent cyanosis
    • Twitching, tremors, and seizures
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Causes

Hypoparathyroidism has multiple etiologies:

  • Postsurgical
  • Autoimmune
  • Sporadic [25]
  • Polyglandular syndromes
  • Activating antibodies to the calcium-sensing receptor [26, 27]
  • Infiltration
  • Parathyroid destruction
  • Copper [11]
  • Malignancy
  • Granulomatous disease [12]
  • Mitochondrial neuropathies
  • Inactivating mutations of the PTH gene [25]
  • DiGeorge syndrome [9]
  • Impaired secretion and/or action of PTH
  • Hypomagnesemia [28]
  • Pseudohypoparathyroidism
  • Hemochromatosis [29]
  • Infarction [30]
  • Hypermagnesemia [31]
  • Medication induced (aluminum, [32] doxorubicin, [28] aminoglycoside, [33] cimetidine, [34] alendronate [35] , omeprazole [36] )
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