Category: Other -
Objective : Hypocalcemia is difficult to treat with calcium supplementation alone when associated with hypomagnesemia. Magnesium levels should be checked and corrected if low. We present such a case.
Methods : A 61-year-old man with history of coronary artery disease (CAD), controlled type 2 diabetes mellitus (DM) on metformin presented to the ER after a fall. Workup for fall was unremarkable. Incidentally calcium (Ca2+) was 5mg/dl (reference range: 8.5-10.1mg/dl), albumin 2.5gm/dl (reference range: 3.4-5gm/dl). Repeat Ca2+ was same (corrected Ca2+ 6.2mg/dl). He was alert and oriented but reported occasional twitching and spasm in the face and hands. His electrocardiogram was unremarkable. Iv 2gm calcium gluconate was started. Repeat Ca2+ was worse <5mg/dl. His magnesium (Mg) level was low 0.7mg/dl (reference range: 1.7-2.4mg/dl), 25 Hydroxy vitamin D was low 6.2ng/ml (reference range: 30-100ng/ml), phosphorus was slightly high 5.2mg/dl (reference range: 2.5-4.9 mg/dl) and intact Parathyroid Hormone (iPTH) was normal 24.7pg/ml (reference range: 11.1-79.5pg/ml).
Results : His home medications were pantoprazole 40 mg daily and Lasix 40 mg daily since a month back. Both medications were stopped. His calcium level improved with the correction of Magnesium. On discharge his Ca2+ was 8.3mg/dl, Mg was 1.5mg/dl. Patient was prescribed magnesium oxide oral 400 mg 3 times a day for the next 3 months.
Discussion : Low Mg with Low Ca2+ could be due to Proton Pump Inhibitor (PPI), diuretics, digoxin, nephrotoxic drugs, alcohol, uncontrolled DM. A study describes hypomagnesemia in people using PPI for more than 1 year1. A study done in 11,490 patients in ICU setting showed 0.028 mg/dL lower adjusted serum magnesium and significantly higher hypomagnesemia (15.6 versus 11 percent) in those taking both PPI and diuretics as compared to taking diuretics only. Also hypomagnesemia was not seen in patients taking PPI only2. Hypocalcemia with diuretic use has increased iPTH, whereas with PPI has normal iPTH. Our patient had normal iPTH suggestive of PPI use, however diuretic cannot be completely ruled out.
Conclusion : When hypocalcemia is not corrected by supplementation, look for Mg. Hypocalcemia out of proportion to hypoalbuminemia associated with hypomagnesemia and normal iPTH can be due to PPI. Regardless of the cause, the gist is to correct Mg before correcting Ca2+, doing otherwise can worsen initial Ca2+ levels and the clinical status as in our case. Mg when given iv, leaks out by urine rapidly. For acute situations, our suggestion is to supplement Mg both by iv and oral. For replenishing Mg stores, oral Mg therapy for months is the prudent approach.
Biswaraj Tharu– Resident, western reserve health education, Youngstown, Ohio
Sijan Basnet– Resident Physician, Reading Hospital, Wyomissing, Pennsylvania
Bishal Khanal– Resident Physician, Western Reserve Health Education, Youngstown, Ohio
Resham Poudel– Resident, Western reserve Health Education
Nisha Kafle– Bachelor in Public Health (BPH), Tribhuvan University
Shailesh Bhattarai– Resident Physician, Western Reserve Health Education/NEOMED program, Youngstown, Ohio
Sonali Koirala– Observer, Trumbull regional medical center, Youngstown, Ohio
Safa Ibrahim– Medical resident, Western Reserve Health Education/ NEOMED, Katy, Texas
western reserve health education
Western Reserve Health Education- PGY1
Internal Medicine Residency
Reading Hospital and Medical Center
West Reading, PA
(Jun 2016- Jun 2019 (expected))
Bachelor of Medicine and Bachelor of Surgery
Institute of Medicine, Tribhuvan University Teaching Hospital
(Nov 2007- May 2014)
Western Reserve Health Education
Internal Medicine Resident
Western Reserve Health Education
500 Gypsy Ln
Youngstown, OH 44504
MBBS, Tribhuvan University, Nepal
Western Reserve Health Education/NEOMED program
Shailesh Bhattarai, M.D., Internal Medicine Resident, PGY1, Western Reserve Health Education, NEOMED
Trumbull regional medical center
B.P.Koirala Institute of Health Sciences