Calcium

Question 1

Hypercalcemia

Answer 1

Ca > 11 mg/dL

Constipation
Fatigue
Depression
Muscle weakness
Coma
Changes in sensorium

WISHbone

Williams syndrome
Ingestion (vit A and D, thiazides)
Skeletal (dysplasias, immobilization/body cast)
Hyperparathyroidism

Question 2

Hypercalcemia treatment

Answer 2

Fluid
Furosemide
EKG monitoring

Calcitonin in rare cases

Question 3

Hypocalcemia

Answer 3

Ionized Ca < 4.5 mg/dL (1 mmol/L)
+ total Ca < 8.5 mg/dL

Painful muscle spasms
Seizures, esp. resistant to diazepam
Vomiting
Prolonged QT

Chvostek sign: tap anterior to earlobe and below cheek bone –> mm. contraction on that side
Trousseau sign: inflate BP cuff >SBP and leave it for 2 min –> carpal mm. spasm on that side
Hypomagnesemia

PINK (causes)

Pseudohypoparathyroidism
Intake deficiency, immune deficiency (DiGeorge)
Nephrotic syndrome (low albumin --> low Ca)
Kidney insufficiency 

Tx: calcium

Question 4

Vitamin D deficiency

Answer 4

Hypocalcemia

Hypophosphatemia

Question 5

Hypoparathyroidism

Answer 5

Hypocalcemia

Hyperphosphatemia

Question 6

Hyperparathyroidism

Answer 6

Hypercalcemia

Hypophosphatemia

Question 7

Pseudohypoparathyroidism

Answer 7

Hypocalcemia
High PTH

Organs are resistant to PTH

Developmental delay
Short
Obese
Moon facies
Calcification of basal ganglia

Question 8

When do u need emergent Ca?

Answer 8

Hypocalcemia
Hyperkalemia
Calcium channel blocker ingestion
Hypermagnesemia

Question 9

Rickets

what are the two types of rickets?

Answer 9

Deficient mineralization of bone at growth plate
-so only occurs before growth plates close

Calcipenic rickets: Ca issue

Phosphopenic rickets: phosphate issue

All types of rickets have elevated alkaline phosphatase

Question 10

Osteomalacia

Answer 10

Deficient mineralization of bone at the bone matrix

Question 11

Rickets presentation

Answer 11

Bone pain
Anorexia
Decreased growth rate
Widened wrists and knees
Delayed teeth eruption, bad tooth enamel
Bowed legs
Rachitic rosary: enlarged costochondral junctions, "pigeon chest"
Craniotabes: softening skull, delayed suture and fontanelle closure, frontal bossing

Kid may be on anti-convulsants
Can occur with liver disease (decreased bile salts –> decreased vitamin D absorption)

Question 12

Calcipenic rickets

Answer 12

Not enough Ca to meet needs of growing bone

• Ca could be normal or low
• phos can sometimes be normal

High PTH always
Bone phoning home for more calcium!

3 types

1. Vitamin D deficient rickets
2. Vitamin D dependent rickets type 1
3. Hereditary vitamin D resistant rickets (vitamin D dependent rickets type 2)

Question 13

Vitamin D deficient rickets

Answer 13

Most common type of rickets
Nutritional

• Breast-feeding without vitamin D supplement
• Little sunlight exposure, dark skinned, born in fall/winter
• Low birth weight, premature, or both
• Infant on strict vegan diet excluding dairy.
• Infant can be born with congenital rickets if mother on a strict nondairy diet
• lactose intolerant kids

Low 25-hydroxy vitamin D

Tx: vitamin D and Ca supplements

Question 14

Vitamin D dependent rickets type 1

Answer 14

Autosomal recessive
Inadequate kidney production of 1,25 – dihydroxy vitamin D (the active metabolite)

Liver is ok, so it is still making 25-hydroxy vitamin D (step 1)

Aka pseudo-vitamin D resistant rickets

Tx: vitamin D2 and 1,25-hydroxy vitamin D

Question 15

Hereditary vitamin D resistant rickets

Aka vitamin D dependent rickets type 2

Answer 15

Autosomal recessive

End organ resistance to vitamin D

Elevated 1,25-dihydroxy vitamin D

Question 16

Phosphopenic rickets

Answer 16

Low phosphate
Ca and PTH may be normal

Usually due to renal phosphate wasting

X-linked hypophosphatemic rickets

• X-linked dominant
• MC in industrialized countries
• too much phosphate lost via kidneys
• Tx: phosphate, 1,25-dihydroxy vitamin D