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Lip Tremor in Hypocalcemia

Authors:
Niraj Kumar at All India Institute of Medical Sciences Rishikesh
Niraj Kumar
Ved Prakash
Ved Prakash
Ved Prakash
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THIEME
212 Letter to the Editor
Lip Tremor in Hypocalcemia
Niraj Kumar1,2 Ved Prakash3
1Department of Neurology, Indira Gandhi Institute of Medical
Sciences, Patna, Bihar, India
2Department of Neurology, All India Institute of Medical Sciences,
Rishikesh, Uttarakhand, India
3Department of Endocrinology, Indira Gandhi Institute of Medical
Sciences, Patna, Bihar, India
Address for correspondence Niraj Kumar, MD, DM, Department of
Neurology, All India Institute of Medical Sciences, Rishikesh 249203,
Uttarakhand, India (e-mail: drnirajkumarsingh@gmail.com).
DOI https://doi.org/
10.1055/s-0039-3399480
ISSN 0976-3147.
©2020 Association for Helping
Neurosurgical Sick People
Neuromuscular hyperexcitability (NH) resulting from hypo-
calcemia commonly manifests as facial twitching and peri-
oral tingling.1 Lip tremor in hypocalcemia has never been
reported to the best of our knowledge. We report a postpar-
tum female, with two previous miscarriages, presenting with
seizures and lip tremor and diagnosed with hypocalcemia.
A 23-year-old woman, 5 days postpartum with past
history of two second-trimester miscarriages presented with
new-onset generalized tonic–clonic seizures and lip trem-
or without fever, headache, or vomiting. Trousseau’s and
Chvostek’s signs were positive, and neurological examina-
tion revealed a rhythmic, 8 to 10 Hz tremor involving upper
lip (►Video 1). Computed tomography of the brain revealed
bilateral basal ganglia, thalamus, subcortical white matter,
red, and dentate nuclei calcification (►Fig. 1). Electroen-
cephalogram was nonconclusive. Blood work-up revealed
reduced calcium of 1.37 mmol/L (normal, 2.14–2.56), raised
phosphate of 8.22 mg/dL (normal, 3–4.5), reduced parathy-
roid hormone of 4 pg/mL (normal, 12–88), and vitamin D
of 9.55 ng/mL (normal, 10–55), thereby suggesting a diag-
nosis of idiopathic hypoparathyroidism. Gynecological
and hematological investigations including anticardiolipin
antibodies returned nonconclusive. We treated her initially
with intravenous calcium gluconate followed by oral elemen-
tal calcium 2 g/d and calcitriol 1.5 g/d. Her symptoms includ-
ing lip tremor subsided over subsequent 4 weeks (►Video 1).
Hypocalcemia is common in pregnancy, mostly due to
hypoparathyroidism and dietary deficiency.2 Long-standing
idiopathic hypoparathyroidism was the cause in our case. NH
resulting from reduced extracellular calcium modulates var-
ious receptors and ion channels,3 commonly manifesting as
muscle spasms, cramps, twitchings, paresthesia, numbness,
and seizure.1 Lip tremor in our case appears related to NH.
J Neurosci Rural Pract 2020;11:212–213
Fig. 1 Noncontrast computed tomography of the brain showing calcifications in bilateral basal ganglia, thalamus, and subcortical white matter
(A) and cerebellum (B).
Video 1
Video of our case shows positive Trousseau’s and Chvostek’s
sign with upper lip tremor at presentation. The second
segment of the video taken at 4 weeks after starting treat-
ment shows absent trousseau’s and Chvostek’s sign with no
upper lip tremor. Online content including video sequences
viewable at: https://www.thieme-connect.com/products/
ejournals/html/10.1055/s-0039-3399480.
Published online: 2020-03-03
213
Journal of Neurosciences in Rural Practice Vol. 11 No. 1/2020
Letter to the Editor
NH may increase uterine irritability leading to miscarriages,4
as reported by our case. Nearly 30 g of calcium is transferred
from mother to the fetus throughout pregnancy with maxi-
mum in the last trimester.2,4 Thus, long-standing hypocalce-
mia in pregnancy is more likely to manifest in the peripartum
period as evidenced in our case. Asymptomatic hypocalcemia
in pregnancy is widely prevalent in India,5 and regular moni-
toring of serum calcium and a calcium-rich diet in pregnancy
is essential.
Authors’ Contributions
N.K.: Conception, design, writing the first article, review,
and critique. V.P.: Review and critique.
Funding
None.
Conict of Interest
None declared.
References
1 Abate EG, Clarke BL. Review of hypoparathyroidism. Front
Endocrinol (Lausanne) 2017;7(JAN):172
2 Almaghamsi A, Almalki MH, Buhary BM. Hypocalce-
mia in pregnancy: a clinical review update. Oman Med J
2018;33(6):453–462
3 Han P, Trinidad BJ, Shi J. Hypocalcemia-induced seizure: demy-
stifying the calcium paradox. ASN Neuro 2015;7(2):1–9
4 Hatswell BL, Allan CA, Teng J, et al. Management of hypopara-
thyroidism in pregnancy and lactation - a report of 10 cases.
Bone Rep 2015;3:15–19
5 Kumar A, Agarwal K, Devi SG, Gupta RK, Batra S. Hypocalcemia
in pregnant women. Biol Trace Elem Res 2010;136(1):26–32
ResearchGate has not been able to resolve any citations for this publication.
Review of Hypoparathyroidism
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  • Jan 2017
Hypoparathyroidism is a rare endocrine disorder in which parathyroid hormone (PTH) production is abnormally low or absent, resulting in low serum calcium and increased serum phosphorus. The most common cause of hypoparathyroidism is parathyroid gland injury or inadvertent removal during thyroid surgery. Current treatments include supplementation with calcium and active vitamin D, with goal albumin-corrected serum calcium level in the low-normal range of 8–9 mg/dl. Complications of the disease include renal dysfunction, nephrocalcinosis, kidney stones, extracellular calcifications of the basal ganglia, and posterior subcapsular cataracts, as well as low bone turnover and increased bone density. Until January 2015, hypoparathyroidism was the only classic endocrine disease without an available hormone replacement. Recombinant human PTH 1-84, full-length PTH, is now available for a selected group of patients with the disease who are not well controlled on the current standard therapy of calcium and active vitamin D. In addition, the role of PTH replacement on quality of life, intracerebral calcifications, cataracts, improving bone turnover, and reduction of renal complications of the disease remains to be further investigated.
View
Management of Hypoparathyroidism in Pregnancy and Lactation – A Report of 10 Cases
Article
Full-text available
  • Jun 2015
Introduction: Hypoparathyroidism in pregnancy is rare, but important, as it is associated with maternal morbidity and foetal loss. There are limited case reports and no established management guidelines. Optimal maintenance of calcium levels during pregnancy is required to minimise the risk of related complications. This study aims to identify causes and examine outcomes of hypoparathyroidism in pregnancy in a cohort of women delivering at a large referral centre. Design and method: The Monash Health maternity service database captures pregnancy and birthing outcomes in over 9000 women each year. We audited this database between 2000 and 2014 to examine the clinical course, treatment and outcomes of pregnant women with hypoparathyroidism. Results: We identified 10 pregnancies from 6 women with pre-existing hypoparathyroidism secondary to idiopathic hypoparathyroidism (n = 3), autosomal dominant branchial arch disorder with hypoparathyroidism (n = 3) and autosomal dominant hypocalcaemia (n = 1), surgery for thyroid cancer (n = 2) and Graves' disease (n = 1). Maternal calcium levels were monitored through pregnancy and management adjusted to maintain normocalcaemia. One woman was delivered by caesarean section at 34 weeks' gestation because of intrauterine growth restriction, and oligohydramnios complicated two other pregnancies. The postpartum period was complicated by severe hypercalcaemia in one woman and by symptomatic, labile serum calcium levels during lactation in another woman, requiring close monitoring over a 6 month period. Conclusion: Although rare, hypoparathyroidism in pregnancy poses a management challenge for clinicians, and co-ordinated care is required by obstetricians and endocrinologists to ensure optimal outcomes for both mother and baby. Continued monitoring of maternal calcium levels during lactation and weaning is essential to avoid the potential complications of either hypercalcaemia or hypocalcaemia.
View
Hypocalcemia-Induced Seizure
Article
Full-text available
  • Mar 2015
Calcium is essential for both neurotransmitter release and muscle contraction. Given these important physiological processes, it seems reasonable to assume that hypocalcemia may lead to reduced neuromuscular excitability. Counterintuitively, however, clinical observation has frequently documented hypocalcemia's role in induction of seizures and general excitability processes such as tetany, Chvostek's sign, and bronchospasm. The mechanism of this calcium paradox remains elusive, and very few pathophysiological studies have addressed this conundrum. Nevertheless, several studies primarily addressing other biophysical issues have provided some clues. In this review, we analyze the data of these studies and propose an integrative model to explain this hypocalcemic paradox. © The Author(s) 2015.
View
Hypocalcemia in Pregnancy: A Clinical Review Update
Article
  • Sep 2018
Though hypocalcemia in pregnancy is not often reported in the literature, it occurs in cases of hypoparathyroidism and in mothers with severe dietary inadequacy. Hypocalcemia during pregnancy can pose numerous problems to the mother and fetus. It is associated with hypertensive disorders and can increase the risk of numerous problems such as preeclampsia and fetal growth disorders. In this review, we summarize the challenges physicians face diagnosing and managing hypocalcemia during pregnancy. A multidisciplinary team including endocrinologists and obstetricians is warranted to ensure appropriate treatment and optimal outcomes
View
Hypocalcemia in Pregnant Women
Article
  • Sep 2009
  • BIOL TRACE ELEM RES
The objective of this study is to estimate the prevalence of hypocalcemia and its correlation with dietary intake of calcium (DICa) and urinary calcium excretion (UCaE) in pregnant women. Healthy pregnant women (n = 543) were enrolled consecutively. DICa was calculated form dietary history. Serum calcium (SCa) and 24-h UCaE was measured. Student t test and Chi-square tests were used to compare the continuous and categorical data in women with and without hypocalcemia (SCa <or= 8.7 mg/dL). Linear regression was applied for determining the independent variables for hypocalcemia. The age and gestation (mean +/- SD) were 21.9 +/- 2.5 years and 18.0 +/- 3.5 weeks, respectively. The body mass index (BMI; mean +/- SD) was 23.3 +/- 3.9 kg/m(2). Seventy-one percent women had an education of less than 10 years. The DICa and SCa were 325 +/- 198 mg and 8.1 +/- 1.5 mg/dL, respectively. The prevalence of hypocalcemia was 66.4% (362/545); all being asymptomatic. There was no significant difference in women with and without hypocalcemia in terms of weight, BMI, monthly family income, DICa, UCaE, and their obstetric outcome. Daily dietary calcium intake was less than the recommended dietary allowances. There was a high prevalence of asymptomatic hypocalcemia in pregnant women of low socio-economic status which was unrelated to their overall nutritional status and daily calcium intake. It did not have any adverse effect on the immediate pregnancy outcome.
View
Hypocalcemia-induced seizure: demystifying the calcium paradox
  • P Han
  • B J Trinidad
  • J Shi
  • Jan 2017
  • 172
  • E G Abate
  • B L Clarke
Abate EG, Clarke BL. Review of hypoparathyroidism. Front Endocrinol (Lausanne) 2017;7(JAN):172
Hypocalcemia-induced seizure: demystifying the calcium paradox
  • Jan 2015
  • 1
  • Han