Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 2063  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
 Table of Contents    
CASE REPORT
Year : 2014  |  Volume : 58  |  Issue : 4  |  Page : 470-472  

Undetected hypoparathyroidism: An unusual cause of perioperative morbidity


Department of Neuroanaesthesiology and Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India

Date of Web Publication17-Aug-2014

Correspondence Address:
Dr. Ashish Chakravarty
Department of Neuroanaesthesiology and Critical Care, Medanta, The Medicity, Gurgaon, Haryana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.139014

Rights and Permissions
 

Routine investigation of serum calcium is not recommended in ASA one and two patients unless abnormalities of calcium metabolism are clinically suspected. The clinical features of hypocalcaemia can often be subtle and may manifest in the presence of associated factors. Hypoparathyroidism, an important cause of hypocalcaemia, often presents as soft tissue calcification (ostosis). Ligamentum flavum ostosis can present with compressive myelopathy requiring laminectomy. We report a case of ligamentum flavum ostosis and subclinical hypocalcaemia due to hypoparathyroidism, who went undetected pre-operatively resulting in significant post-operative morbidity.

Keywords: Hypocalcaemia, hypoparathyroidism, ligamentum flavum ostosis


How to cite this article:
Chakravarty A, Anand S, Sapra H, Mehta Y. Undetected hypoparathyroidism: An unusual cause of perioperative morbidity. Indian J Anaesth 2014;58:470-2

How to cite this URL:
Chakravarty A, Anand S, Sapra H, Mehta Y. Undetected hypoparathyroidism: An unusual cause of perioperative morbidity. Indian J Anaesth [serial online] 2014 [cited 2018 Aug 21];58:470-2. Available from: http://www.ijaweb.org/text.asp?2014/58/4/470/139014


   Introduction Top


Hypocalcaemia can be an important cause for delayed recovery in the post-operative period and can significantly influence post-operative morbidity. [1] Hypoparathyroidism is an important cause of hypocalcaemia. [2] We report a case of laminectomy and decompression of the spine with increased morbidity because of undetected pre-existing hypoparathyroidism. Consent of the patient was obtained before publication of this case report.


   Case Report Top


A 45-year-old male of 65 kg, presented with a history of low backache and weakness of both lower limbs for last 2 years, and urinary retention and constipation for the last 2 days. He had full power in the upper limb and Grade 3 power in the lower limbs. A magnetic resonance image (MRI) of the dorso-lumbar spine showed thickened ligamentum flavum indenting the thecal sac from D9 to D12 with cord oedema. Pre-anaesthetic examination was normal except for distended, but soft abdomen without clinical evidence of ascites or organomegaly. Bowel sounds were present. His urinary bladder was catheterized. Pre-operative investigations were normal. He was admitted for laminectomy and decompression of the spine.

Standard monitoring, including invasive blood pressure and arterial blood gas (ABG) was used intraoperatively. Anaesthesia was induced with propofol 140 mg, fentanyl citrate 150 μg and rocuronium bromide 50 mg and trachea wase intubated. Mechanical prophylaxis for deep vein thrombosis and warm air blanket were used intraoperatively. His post-induction ABG readings were normal. Anaesthesia was maintained with 2% sevoflurane in 50% O 2 in air, propofol infusion at 25 μg/kg/min and vecuronium bromide at 2 mg/h. The surgery lasted 5 h. Intermittent fentanyl (total 500 μg) was used for analgesia intraoperatively. Hydration was maintained with intravenous (IV) 3.5 L 0.9% saline, 0.5 L colloid (tetra starch). Noradrenaline at 2-4 μg/min was started in view of refractory hypotension. Blood loss was 250 ml. and urine output was 250 ml. ABG obtained 2 h post-induction showed metabolic acidosis. Severe canal stenosis and cord oedema was noticed from D9 to D12. Methylprednisolone was started as 30 mg/kg bolus followed by infusion at 5.4 mg/kg/h. At the end of surgery, the patient had inadequate motor power and respiratory effort. A repeat ABG showed metabolic acidosis. His blood sugar was 246 mg% and urine ketone was negative. Insulin infusion was started, and the patient was shifted to intensive care unit for elective ventilation. A central venous line inserted showed a central venous pressure of 1-2 cm H 2 O. Overnight fluid therapy resolved acidosis and oliguria. Next day the patient was extubated. Kidney function test (KFT) revealed high normal values. Serum sodium, potassium, and thyroid status was found normal. At this time, his upper limb power was almost normal while power in both lower limbs was 1/5 requiring continuation of methylprednisolone. Six hours after extubation he developed tense abdominal distension and respiratory distress. His ABG revealed respiratory alkalosis. He was reintubated and ventilated. His chest X-ray and echocardiogram were normal. Due to inconclusive abdominal ultrasound report (USG) a computerized tomography of the abdomen was obtained which showed colonic gaseous distension without free fluid in the abdomen. Ryle's tube was inserted and injection neostigmine started at 2.5 mg/h for 2 h. On post-operative day (POD) 2 the patient re-developed deranged KFT along with high-grade fever. Blood, urine, and tracheal aspirate were sent for cultures and sensitivity and antibiotics upgraded as per culture reports. Sepsis and "pancreatitis profile" revealed serum procalcitonin 4.4 ng/ml, hypocalcaemia (serum calcium 4.1 mg%), hypoalbuminemia (2 g%), but normal serum amylase and lipase. Factitious hypocalcaemia was ruled out by serum ionized calcium 0.5 mmol/L. Further investigations revealed hyperphosphatemia, low parathormones and normal magesium levels. IV albumin was started to correct hypoalbuminemia. Due to refractory hypocalcaemia, high doses of IV calcium (450 mg elemental calcium 4 th h), was required along with oral calcitriol 0.5 μg q8h. On POD 3 renal functions and acidosis started to resolve. Despite 2 days trial of neostigmine, prokinetics and laxatives, his abdominal symptoms persisted. Digital examination ruled out faecal impaction. Decompressive sigmoidoscopy was performed and total parenteral nutrition (TPN) was started.

Over next 2 days gastrointestinal (GI) symptoms, procalcitonin and total leucocyte count started to decrease. Serum calcium increased to 7.7 mg%.

On POD 9 the patient was extubated. Eighteen hours later, he was reintubated and ventilated due to severe tachypnoea and decreased consciousness. Pulmonary embolism was ruled out by doing a USG Doppler lower limbs and echocardiography. MRI spine did not reveal any fresh changes. Cerebrospinal fluid analysis ruled out meningitis. On POD 13 he was tracheostomised.

Patient showed steady improvement from next day. He was weaned off the ventilator fully conscious with good power in all limbs, normal calcium and albumin levels, and no GI symptoms. He was later decannulated and discharged with on-going treatment and advice for follow-up.


   Discussion Top


Ossification of the ligamentum flavum is a rare cause of thoracic myelopathy. Neurologic improvement and good recovery usually occurs following decompression laminectomy. [3] However in our case, there was considerable post-operative morbidity.

Our patient must have been hypovolemic pre-operatively which would have masked hypoalbuminemia. This got manifested once the patient became volume repleted. The patient had been harbouring urinary tract infection (UTI) which was missed in the absence of urine microscopic examination. This got aggravated perioperatively due to stress of surgery and hyperglycaemia.

Hyperglycaemia in our non-diabetic patient was because of steroids and sepsis due to UTI. The decreased urine output, and metabolic acidosis was the combined result of sepsis and intraoperative usage of noradrenaline. [4],[5] Antidiuretic hormone release due to stress of surgery [6] may have added to oliguria.

The manifestations of hypocalcaemia can be varied depending upon its rapidity of development. [2] Spasticity is a known clinical manifestation of hypocalcaemia, which in our case manifested as a tense abdomen. As calcium is an important mediator of excitation-contraction coupling, colonic distension and paralytic ileus is possible due to hypocalcaemia. [7],[8]

The best-studied treatment of acute colonic pseudo-obstruction is IV neostigmine, which leads to prompt colon decompression in the majority of patients after a single infusion. [9] However in our case, actual improvement started to occur only after normalisation of calcium levels.

Alkalosis and hypokalaemia aggravate the clinical manifestations of hypocalcaemia. [10] In this patient, pain and discomfort of tense abdominal distension possibly caused hyperventilation and respiratory alkalosis exaggerating the respiratory muscle fatigue due to hypocalcaemia. Hypokalaemia due to steroid and insulin compounded the respiratory muscle weakness.

Methylprednisolone, with predominantly glucocorticoid activity, decreases calcium absorption from the gut and increases its excretion in the urine. [11] It also causes hypokalaemia and alkalosis by excretion of potassium and hydrogen ions through renal tubules. [12]

Increased serum free fatty acids due to TPN lower serum ionized calcium. [10] Sepsis causes hypocalcaemia mediated by inflammatory cytokines. [13]

Our patient was diagnosed as primary hypoparathyroidism, with severe hypocalcaemia, sepsis and acute renal failure. The aetiological diagnosis was established after doing a 'pancreatitis profile' in view of fever, abdominal symptoms, and acute kidney injury (AKI), which revealed hypocalcaemia. Hypoparathyroidism is an important cause of hypocalcaemia. A review into the literature of hypoparathyroidism revealed hyperostosis as a feature due to chronic hypocalcaemia. [2] This explained the ligamentum flavum thickening.To the best of our knowledge, this is the first report correlating hypoparathyroidism, paralytic ileus and AKI.


   Conclusion Top


Hypocalcaemia though not an uncommon entity is frequently overlooked. Its presence along with its etiological and aggravating factors should always be sought where recovery gets delayed.

 
   References Top

1.Garg R, Punj J, Pandey R, Darlong V. Delayed recovery due to exaggerated acid, base and electrolyte imbalance in prolonged laparoscopic repair of diaphragmatic hernia. Saudi J Anaesth 2011;5:79-81.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Stoelting RK, Dierdorf SF. Endocrine diseases. In: Anesthesia and Co-Existing Disease. 4 th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2002. p. 396-440.  Back to cited text no. 2
    
3.Fong SY, Wong HK. Thoracic myelopathy secondary to ligamentum flavum ossification. Ann Acad Med Singapore 2004;33:340-6.  Back to cited text no. 3
    
4.Richer M, Robert S, Lebel M. Renal hemodynamics during norepinephrine and low-dose dopamine infusions in man. Crit Care Med 1996;24:1150-6.  Back to cited text no. 4
    
5.Schade DS. The role of catecholamines in metabolic acidosis. Ciba Found Symp 1982;87:235-53.  Back to cited text no. 5
    
6.Pillai BP, Unnikrishnan AG, Pavithran PV. Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder. Indian J Endocrinol Metab 2011;15 Suppl 3:S208-15.  Back to cited text no. 6
    
7.Doherty TJ. Postoperative ileus: Pathogenesis and treatment. Vet Clin North Am Equine Pract 2009;25:351-62.  Back to cited text no. 7
    
8.Delesalle C, Dewulf J, Lefebvre RA, Schuurkes JA, Van Vlierbergen B, Deprez P. Use of plasma ionized calcium levels and Ca2+substitution response patterns as prognostic parameters for ileus and survival in colic horses. Vet Q 2005;27:157-72.  Back to cited text no. 8
    
9.Saunders MD, Kimmey MB. Systematic review: Acute colonic pseudo-obstruction. Aliment Pharmacol Ther 2005;22:917-25.  Back to cited text no. 9
    
10.Stoelting RK, Dierdorf SF. Water, electrolyte and acid-base disturbances. In: Anesthesia and Co-Existing Disease. 4 th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2002. p. 373-94.  Back to cited text no. 10
    
11.Reid IR. Glucocorticoid osteoporosis - Mechanisms and management. Eur J Endocrinol 1997;137:209-17.  Back to cited text no. 11
    
12.Rickman T, Garmany R, Doherty T, Benson D, Okusa MD. Hypokalemia, metabolic alkalosis, and hypertension: Cushing's syndrome in a patient with metastatic prostate adenocarcinoma. Am J Kidney Dis 2001;37:838-46.  Back to cited text no. 12
    
13.Müller B, Becker KL, Kränzlin M, Schächinger H, Huber PR, Nylèn ES, et al. Disordered calcium homeostasis of sepsis: Association with calcitonin precursors. Eur J Clin Invest 2000;30:823-31.  Back to cited text no. 13
    




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References

 Article Access Statistics
    Viewed1177    
    Printed26    
    Emailed0    
    PDF Downloaded395    
    Comments [Add]    

Recommend this journal