Endocrine Abstracts

Introduction: Hypocalcemia has been linked to a decreased myocardial performance and even congestive heart failure, while acute chest-pain as leading symptom of hypocalcemia is an unusual presentation.

Case report: A 29-year-old Caucasian man presented to the emergency department with relapsing chest-pain since several days, lasting seconds sometimes lasting several minutes, radiating to the left shoulder and combined with mild tingling in the neck. A detailed history revealed occasional muscle cramps on exercise or due to long sitting in one position. The patient also felt tired and had sleep disturbances. His medical history was unremarkable and he never underwent an operation. In the family history, nephrolithiasis in the grandfather and the great-grand father was striking. The initial physical examination revealed no pathologies, the blood pressure and heart rate were normal. The ECG showed a prolonged QTc of 465 ms but was otherwise unremarkable. The laboratory findings showed normal results (complete blood count, renal and liver function tests, markers of inflammation, high sensitive Troponin T and D-dimers) except of a severe hypocalcemia (total calcium: 1.42 nmol/l albumin-adjusted: of 1.5 nmol/l, ionized 0.76 nmol/l) and hyperphosphatemia of 2.09 nmol/l. Further tests revealed a magnesemia of 0.7 nmol/l, a Vitamin-D of 27 nmol/l and iPTH of 14.9 ng/l (reference range: 15.0–65.0 ng/l). The TSH was 1.68 mIU/l; the urinary excretion of calcium (0.8 mmol/l) was low. Based on these results, we established a diagnosis of idiopathic hypoparathyroidism and started a therapy with calcitriol (initial dose 0.25 µg twice daily, later increased to 0.25 µg three times a day) and calcium and magnesium supplementation (2 g/d and 10 mmol/d, respectively). Already the next day on the therapy, the symptoms vanished and the patient could be discharged. In further follow-up, normal calcium and phosphate values could be reached. Screening for possible associated organ-specific autoimmune diseases was negative and there were no signs of candidiasis. There were no signs of hemochromatosis or infiltrative/granulomatous disease.

Discussion: Here we present a rare case of idiopathic hypoparathyroidism which probably proceeded over years until presentation with severe relapsing chest pain. Chronic severe hypocalcemia can present like an acute coronary syndrome. The cause remains unclear; a possible autoimmune background cannot be excluded.