COVID-19-Induced Refractory Symptomatic Hypocalcemia in a Patient With Parathyroid Gland Reimplantation.

IF 0.9 Q4 ENDOCRINOLOGY & METABOLISM
Case Reports in Endocrinology Pub Date : 2024-09-24 eCollection Date: 2024-01-01 DOI:10.1155/2024/6375828
Crystal Tse, Ho-Man Yeung
{"title":"COVID-19-Induced Refractory Symptomatic Hypocalcemia in a Patient With Parathyroid Gland Reimplantation.","authors":"Crystal Tse, Ho-Man Yeung","doi":"10.1155/2024/6375828","DOIUrl":null,"url":null,"abstract":"<p><p><b>Background:</b> Several cases of severe hypocalcemia in the setting of COVID-19 have been reported. The proposed mechanisms include direct viral interaction with ACE2 receptors in the parathyroid gland, viral chelation of calcium, worsening hypovitaminosis D, critical illness leading to unbound fatty acids binding calcium, and inflammatory cytokines leading to PTH resistance. Given the life-threatening nature of hypocalcemia, this underrecognized phenomenon should be on the forefront of the clinician's attention. This case highlights a rare manifestation of COVID-19 and further complicated by the patient's reimplanted parathyroid gland. <b>Presentation:</b> A 73-year-old female with primary hyperparathyroidism status post parathyroidectomy with reimplantation in the left forearm presented with 4 days of viral syndrome, found to have tetany and Chvostek's sign on physical exam. Pertinent laboratory abnormalities included calcium 5.3 mg/dL, ionized calcium 0.44 mmol/L, magnesium 1.4 mg/dL, phosphorous 5.5 mg/dL, PTH 242 pg/mL, and 25-OH vitamin D 56 ng/mL. Chest CT revealed multifocal pneumonia consistent with positive COVID-19 testing. She was subsequently admitted to the ICU for severe, symptomatic hypocalcemia and was initiated on a continuous calcium infusion, remdesivir, baricitinib, and steroids. Tetany resolved after 9 g calcium repletion, and she was transferred to the medical floor with an ionized calcium of 0.83 mmol/L. On hospital day 3, repeat ionized calcium was 0.78 mmol/L despite ongoing repletion. Given the persistence of hypocalcemia, a repeat PTH level was obtained which remained high at 487 pg/mL, suggesting ongoing PTH interference in the setting of COVID-19. PTH was obtained from the right (nonimplanted) arm which was normal at 74 pg/mL. This indicated an appropriate PTH response from the reimplanted gland, and that ongoing hypocalcemia may be due to insufficient PTH function to maintain systemic calcium levels or a peripheral interference with PTH level. With continued calcium supplementation and treatment of COVID-19, the patient's calcium stabilized at 8.6 mg/dL. She was discharged on oral calcium supplementation with endocrinology follow-up. <b>Conclusion:</b> Acute hypocalcemia strongly correlates with a profound inflammatory response in COVID-19 patients. This case corroborates the cytokine/PTH hypothesis. This patient had a high PTH sampled near the reimplanted gland but an inappropriately normal PTH from the nonimplanted arm, indicating that direct viral interaction interfering with PTH release is an unlikely mechanism. This case represents a scenario where PTH can be sampled directly from the source and this type of model could aid in the process of determining the etiology of hypocalcemia in COVID-19.</p>","PeriodicalId":9621,"journal":{"name":"Case Reports in Endocrinology","volume":null,"pages":null},"PeriodicalIF":0.9000,"publicationDate":"2024-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11444793/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Case Reports in Endocrinology","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1155/2024/6375828","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/1/1 0:00:00","PubModel":"eCollection","JCR":"Q4","JCRName":"ENDOCRINOLOGY & METABOLISM","Score":null,"Total":0}
引用次数: 0

Abstract

Background: Several cases of severe hypocalcemia in the setting of COVID-19 have been reported. The proposed mechanisms include direct viral interaction with ACE2 receptors in the parathyroid gland, viral chelation of calcium, worsening hypovitaminosis D, critical illness leading to unbound fatty acids binding calcium, and inflammatory cytokines leading to PTH resistance. Given the life-threatening nature of hypocalcemia, this underrecognized phenomenon should be on the forefront of the clinician's attention. This case highlights a rare manifestation of COVID-19 and further complicated by the patient's reimplanted parathyroid gland. Presentation: A 73-year-old female with primary hyperparathyroidism status post parathyroidectomy with reimplantation in the left forearm presented with 4 days of viral syndrome, found to have tetany and Chvostek's sign on physical exam. Pertinent laboratory abnormalities included calcium 5.3 mg/dL, ionized calcium 0.44 mmol/L, magnesium 1.4 mg/dL, phosphorous 5.5 mg/dL, PTH 242 pg/mL, and 25-OH vitamin D 56 ng/mL. Chest CT revealed multifocal pneumonia consistent with positive COVID-19 testing. She was subsequently admitted to the ICU for severe, symptomatic hypocalcemia and was initiated on a continuous calcium infusion, remdesivir, baricitinib, and steroids. Tetany resolved after 9 g calcium repletion, and she was transferred to the medical floor with an ionized calcium of 0.83 mmol/L. On hospital day 3, repeat ionized calcium was 0.78 mmol/L despite ongoing repletion. Given the persistence of hypocalcemia, a repeat PTH level was obtained which remained high at 487 pg/mL, suggesting ongoing PTH interference in the setting of COVID-19. PTH was obtained from the right (nonimplanted) arm which was normal at 74 pg/mL. This indicated an appropriate PTH response from the reimplanted gland, and that ongoing hypocalcemia may be due to insufficient PTH function to maintain systemic calcium levels or a peripheral interference with PTH level. With continued calcium supplementation and treatment of COVID-19, the patient's calcium stabilized at 8.6 mg/dL. She was discharged on oral calcium supplementation with endocrinology follow-up. Conclusion: Acute hypocalcemia strongly correlates with a profound inflammatory response in COVID-19 patients. This case corroborates the cytokine/PTH hypothesis. This patient had a high PTH sampled near the reimplanted gland but an inappropriately normal PTH from the nonimplanted arm, indicating that direct viral interaction interfering with PTH release is an unlikely mechanism. This case represents a scenario where PTH can be sampled directly from the source and this type of model could aid in the process of determining the etiology of hypocalcemia in COVID-19.

COVID-19诱发甲状旁腺再植患者难治性症状性低钙血症
背景:据报道,COVID-19导致了数例严重的低钙血症。提出的机制包括病毒与甲状旁腺中的 ACE2 受体直接相互作用、病毒螯合钙、维生素 D 过低的恶化、危重病导致未结合的脂肪酸与钙结合,以及炎性细胞因子导致 PTH 抗性。鉴于低钙血症具有危及生命的性质,这种未得到充分认识的现象应引起临床医生的高度重视。本病例强调了COVID-19的一种罕见表现,患者重新植入的甲状旁腺使病情进一步复杂化。表现:一名73岁的女性患者,原发性甲状旁腺功能亢进,甲状旁腺切除术后在左前臂再植了甲状旁腺,出现病毒综合征4天,体格检查时发现有四肢抽搐和Chvostek征。相关实验室异常包括血钙 5.3 mg/dL、离子钙 0.44 mmol/L、镁 1.4 mg/dL、磷 5.5 mg/dL、PTH 242 pg/mL、25-OH 维生素 D 56 ng/mL。胸部 CT 显示多灶性肺炎,与 COVID-19 检测阳性一致。随后,她因严重的无症状低钙血症被送入重症监护室,并开始持续输注钙剂、雷米替韦、巴利替尼和类固醇。补钙 9 克后,四肢抽搐症状缓解,她被转到内科楼层,离子钙为 0.83 mmol/L。住院第 3 天,尽管持续补钙,她的离子钙仍为 0.78 mmol/L。鉴于低钙血症持续存在,再次检测了 PTH 水平,结果仍高达 487 pg/mL,表明 COVID-19 正在干扰 PTH。从右臂(未植入)获得的 PTH 值为 74 pg/mL,正常。这表明再植腺体有适当的 PTH 反应,而持续的低钙血症可能是由于 PTH 功能不足以维持全身钙水平或外周干扰 PTH 水平所致。通过持续补充钙剂和使用 COVID-19 治疗,患者的血钙稳定在 8.6 mg/dL。患者出院后继续口服钙剂并接受内分泌科随访。结论急性低钙血症与 COVID-19 患者的严重炎症反应密切相关。本病例证实了细胞因子/PTH 假说。该患者在再植腺体附近采样时PTH较高,但未植入腺体的手臂PTH却异常正常,这表明病毒直接相互作用干扰PTH释放的机制不太可能。该病例代表了一种可以直接从源头采样 PTH 的情况,这种类型的模型有助于确定 COVID-19 低钙血症的病因。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
Case Reports in Endocrinology
Case Reports in Endocrinology ENDOCRINOLOGY & METABOLISM-
CiteScore
2.10
自引率
0.00%
发文量
45
审稿时长
13 weeks
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信