A 33-year-old woman with history of diverticulitis status post hemicolectomy and idiopathic hypoparathyroidism presented with tetany and facial twitching for 3 months. She was transferred to a tertiary medical center for refractory tetany. She presented to her physician earlier in the week for diffuse muscle cramps and facial twitching. On review of her medical record, she had been admitted 3 times in the previous 2 months for similar complaints and was subsequently diagnosed with idiopathic hypoparathyroidism with critically low parathyroid hormone (<4.0 pg/mL) and corrected calcium levels (6.86 mg/dL) but with a normal 25-hydroxyvitamin D level (38.5 ng/mL). Family history was negative for autoimmune illness. Physical examination was significant for positive Chvostek’s sign and Trousseau’s sign, and her feet were fully extended and adducted (Figure). On each prior admission the patient was administered intravenous calcium gluconate, magnesium sulfate, and daily oral calcium carbonate solution, with improvement in both ionized calcium levels and symptoms until discharge. As an outpatient, however, she required increasing doses and frequencies of oral calcitriol and calcium carbonate. On maximum doses she continued to suffer from intractable symptoms, with critically low calcium levels despite reporting excellent compliance with her medications. She also developed anxiety from recurrence of her symptoms. Each time she was discharged home with home care and nursing requirements, on coordinated follow-up she continued to present with recurrent tetany with hypocalcemia. Despite multiple efforts, the patient could not be sustained on an oral regimen.
Assessment
We reanalyzed her history, completed a focused physical examination, and performed a detailed review of her laboratory and imaging findings. A nutritionist was consulted to identify dietary requirements and to increase total body stores of calcium while identifying losses because the patient’s diet consisted mainly of poultry, rice, pasta, and vegetables. Eventually it was discovered that the patient suffered from chronic loose stools, with roughly 2-5 bowel movements daily, which were progressively increasing in frequency and quantity throughout the day. Furthermore, she reported a significant weight loss of 6 pounds in a period of less than 2 weeks. Her husband noted the patient would take a separate pair of clothing to work daily: she would soil her clothes so often that it became a regular component of her lifestyle, and she did not think much of this as a symptom. Retrospective review of calcium levels showed an estimated daily loss of 0.27 mg/dL over a 10-day period, with a daily 24-hour urinary calcium excretion ratio of 0.001. This shows the importance of going through a meticulous review of daily activities, exposures, and eating habits. In this case a review of the patient’s bowel movements, although not felt to be of concern for the patient, was central to her underlying mechanism of disease and subsequent hospitalizations.
Serologic workup revealed an elevated level of tissue transglutaminase antibody and presence of immunoglobulin A endomysial antibody, suggestive of gluten-sensitive enteropathy. A computed tomography scan of the abdomen and pelvis was normal. Celiac disease was diagnosed on the basis of the results of these tests, and hence a gluten-free diet was used.
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-Sachin R. Patel, MD, Raymond J. Shashaty, MD, Philip Denoux, MD
This article originally appeared in the December 2017 issue of The American Journal of Medicine.
