Hypocalcemia and hungry bone syndrome: a life-threatening duo

Stephanie Rivera-Rivera, Critical Care Service, Veterans Hospital San Juan, San Juan, Puerto Rico
William Rodríguez-Cintrón, Pulmonary & Critical Care Service; Pulmonary & Critical Care Service Chief. Veterans Hospital San Juan, San Juan, Puerto Rico

In end-stage renal disease (ESRD) patients who undergo parathyroidectomy, the degree of post-surgery hypocalcemia correlates with the degree of secondary hyperparathyroidism developed over time due to the high bone turnover followed by sudden decrease in PTH activity and increased bone resorption. When hypocalcemia becomes severe or persistent despite treatment, patients had developed hungry bone syndrome. Such patients are at increased risk of tetany, arrhythmias, and seizures, among other complications. This is the case of a 31-year-old man who presented to the emergency department with symptomatic hypocalcemia despite aggressive calcium replacement after a parathyroidectomy 2 months prior. He also presented with hyperkalemia, hyperphosphatemia, and elevated alkaline phosphatase; disturbances usually related to hungry bone syndrome. Severe hypocalcemia and moderate hyperkalemia predispose patients to dangerous arrhythmias, and inte-restingly, this patient demonstrated dynamic changes in the EKG, demonstrating susceptibility to this. For this, the patient received continuous calcium replacement that provided him with membrane stabilization until kayexalate took effect, and the patient was able to receive hemodialysis. This case illustrates the importance of adequate pre-op optimization of these patients and early recognition and aggressive treatment of this complication, most seen in ESRD patients, to avoid serious compli-cations such as life-threatening cardiac arrhythmias.

Keywords: Case report. Hypocalcemia. Parathyroidectomy.