Hypocalcaemia

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Hypocalcemia

Calcium within the periodic table

Classification and external resources

Specialty

Endocrinology

ICD-10

E83.5

eMedicine

article/241893

Patient UK

Hypocalcemia

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Hypocalcaemia, also spelled hypocalcemia, is low calcium levels in the blood serum.[1] The normal
range is 2.12.6 mmol/L (8.810.7 mg/dL, 4.35.2 mEq/L) with levels less than 2.1 mmol/L defined
as hypocalcemia.[2][3][4] Mildly low levels that develop slowly often have no symptoms. [5][6] Otherwise
symptoms may include numbness, muscle spasms, seizures, confusion, or cardiac arrest.[2][5]
Common causes include hypoparathyroidism and vitamin D deficiency.[5] Others causes
include kidney failure, pancreatitis, calcium channel blocker overdose, rhabdomyolysis, tumor lysis
syndrome, and medications such as bisphosphonates.[2] Diagnosis should generally be confirmed
with a corrected calcium or ionized calcium level.[5] Specific changes may be seen on
an electrocardiogram (ECG).[2]
Initial treatment for severe disease is with intravenous calcium chloride and possibly magnesium
sulfate.[2] Other treatments may include vitamin D, magnesium, and calcium supplements. If due
to hypoparathyroidism, hydrochlorothiazide, phosphate binders, and a low salt diet may also be
recommended.[5] About 18% of people who are in hospital have hypocalcemia.[6]
Contents
[hide]

1Signs and symptoms

2Causes

3Mechanism

4Diagnosis

5Management

6See also

7References

8External links

Signs and symptoms[edit]

The neuromuscular symptoms of hypocalcemia are caused by a positive bathmotropiceffect due to
the decreased interaction of calcium with sodium channels. Since calcium blocks sodium channels
and inhibits depolarization of nerve and muscle fibers,[clarification needed] diminished calcium lowers the
threshold for depolarization.[7] The symptoms can be recalled by the mnemonic "CATS go numb"Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and
lips.

Petechiae which appear as on-off spots, then later become confluent, and appear
as purpura (larger bruised areas, usually in dependent regions of the body).

Oral, perioral and acral paresthesias, tingling or 'pins and needles' sensation in and around
the mouth and lips, and in the extremities of the hands and feet. This is often the earliest
symptom of hypocalcaemia.

Carpopedal and generalized tetany (unrelieved and strong contractions of the hands, and in
the large muscles of the rest of the body) are seen.

Latent tetany

Trousseau sign of latent tetany (eliciting carpal spasm by inflating the blood
pressure cuff and maintaining the cuff pressure above systolic)

Chvostek's sign (tapping of the inferior portion of the cheekbone will produce facial
spasms)[8]

Tendon reflexes are hyperactive

Life-threatening complications

Laryngospasm

Cardiac arrhythmias

Effects on cardiac output

Negative chronotropic effect, or a decrease in heart rate.

Negative inotropic effect, or a decrease in contractility

ECG changes include the following:

Intermittent QT prolongation, or intermittent prolongation of the QTc (corrected QT

interval) on the EKG (electrocardiogram) is noted. The implications of intermittent QTc
prolongation predisposes to life-threatening cardiac electrical instability (and this is therefore
a more critical condition than constant QTc prolongation). This type of electrical instability
puts the patient at high risk of torsades de pointes, a specific type of ventricular
tachycardia which appears on an EKG (or ECG) as something which looks a bit like a sine
wave with a regularly increasing and decreasing amplitude. (Torsades de pointes can cause
death, unless the patient can be medically or electrically cardioverted and returned to a
normal cardiac rhythm.)

Causes[edit]
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Hypoparathyroidism is a common cause of hypocalcemia. Calcium is tightly regulated by

the parathyroid hormone (PTH). In response to low calcium levels, PTH induces the kidneys to
reabsorb calcium, the kidneys to increase production of calcitriol (the active form of vitamin D)
thereby increasing intestinal absorption of calcium, and the bones to release calcium. These actions
lead to a re-balance in the blood calcium levels. However, in the setting of absent, decreased, or
ineffective PTH hormone, the body loses this regulatory function, and hypocalcemia ensues.
Hypoparathyroidism is commonly due to surgical destruction of the parathyroid glands via
parathyroidectomy or neck dissection for head and neck cancers. Hypoparathyroidism may also be
due to autoimmune destruction of the glands.

Eating disorders

Prolonged vomiting (e.g. with a viral illness)

Exposure to mercury, including infantile acrodynia

Excessive dietary magnesium, as with supplementation. [citation needed]

Excessive dietary zinc, as with supplementation (causes rapid hypocalcemia).

Prolonged use of medications/laxatives containing magnesium

Chelation therapy for metal exposure, particularly EDTA

Osteoporosis treatment or preventive agents, such as bisphosphonates and denosumab.

Agents for the treatment of hypercalcemia, such as Calcitonin.

Chronic kidney failure

Absent active vitamin D

Decreased dietary intake

Decreased sun exposure

Defective Vitamin D metabolism

Anticonvulsant therapy

Vitamin-D dependent rickets, type I

Ineffective active vitamin D

Intestinal malabsorption

Vitamin-D dependent rickets, type II

Pseudohypoparathyroidism

Severe acute hyperphosphataemia

Tumour lysis syndrome

Acute kidney failure

Rhabdomyolysis (initial stage)

Exposure to hydrofluoric acid

As a complication of pancreatitis

Alkalosis, often caused by hyperventilation

As blood plasma hydrogen ion concentration decreases, caused by respiratory or

metabolic alkalosis, the concentration of freely ionized calcium, the biologically active
component of blood calcium, decreases. Because a portion of both hydrogen ions and
calcium are bound to serum albumin, when blood becomes alkalotic, the 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. This hypocalcaemia related to alkalosis is
partially responsible for the cerebral vasoconstriction that causes
the lightheadedness, fainting, and paraesthesia often seen with hyperventilation.

Tetany may also be seen with this condition.

Neonatal hypocalcemia

Very low birth weight (less than 1500 grams)

Gestational age less than 32 weeks