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Proton pump inhibitors are widely prescribed but their long-term use can expose patients to adverse effects. Some of these are not very well known, including hypomagnesemia. Hypomagnesemia can be manifested by cardiac complications such as supraventricular arrhythmia or QT prolongation, increasing the risk of torsade de pointe. We present a case of atrial fibrillation triggered by severe hypomagnesemia secondary to proton pump inhibitor use and exacerbated by thiazide diuretic treatment. Conversion to sinus rhythm showed a prolonged corrected QT interval. We approach the pathophysiology and the electrophysiologic effects of hypomagnesemia.

Hypocalcémie subclinique dans les élevages de bovins laitiers des Monts du Lyonnais (France) et ses conséquences sur la santé. 24. Rencontres autour des recherches Ruminants (3R)

Many apheresis techniques can be performed in a blood-bank facility or a hemodialysis (HD) facility. However, it makes sense to perform apheresis in a hemodialysis facility as apheresis involves extra-corporeal circuits and because HD can be performed at the same time as apheresis (tandem procedure). Apheresis techniques comprise therapeutic plasma exchange, double-filtration plasmapheresis, and its derivative (rheopheresis and LDL-apheresis), and immunoadsorption (specific and semi-specific). We have setup an apheresis platform in our hospital that fulfills health recommendations. This process has involved financial investment and significant human resources, and has enabled us to network with different specialties (neurology, hematology, vascular medicine). We have setup protocols according to the type of pathology to be treated by apheresis, and to monitor clinical and biological data for each apheresis session. The main side effects of apheresis are a fall in blood pressure when a session is initiated, an increase in fluid overload, hypocalcemia, and the loss of some essential plasmatic factors. However, these side-effects are easily identified and can be properly managed in real time. Within two-years, we have performed 1845 apheresis sessions (134 patients). Of these, 66 received apheresis before and/or after kidney transplantation for ABO and/or HLA incompatibility (desensitization), for humoral rejection, or in the setting of relapsing focal-segmental glomerulosclerosis. Our patients' outcomes have been similar to those reported in the literature. The other 68 patients had various conditions. Because our program is now well-established, we are currently forming a specialist center to train physicians and nurses in the various apheresis techniques/procedures.

The hypercalcemia is defined as a blood calcium range above 2.6 mmol/l. Its prevalence is variable in different studies and it is comprised between 2 and 8/1000 in the general population. The primary hyperparathyroidism (PHP) and cancers are both responsible for about 80 per cent to 90 per cent of causes of hypercalcemia1. The PHP is the first ambulatory cause of hypercalcemia. Contrarily to this, the neoplastic etiology is mainly seen in the hospital settings. The other causes of the hypercalcemia are vitamin D overdose, secondary hypercalcemia due to medications intake and familial hypocalciuric hypercalcemia which will be discussed in this article. The hypocalcemia is defined as a blood calcium range underneath 2.2 mmol/l. The most common etiologies are the postoperative hypopara-thyroidism as a complication of approximatively 1.5 % of thyroidectomies2, the vitamin D deficiency and terminal chronic kidney failure. The other rare causes such as autoimmune hypoparathyroidism, parathyroid agenesis, pseudoparathyroidism and hypomagnesemia will be discussed in this article.L’hypercalcémie est définie par une calcémie supérieure à 2,6 mmol/l. Sa prévalence varie, selon les études, entre 2 et 8/1000 dans la population générale. L’hyperparathyroïdie primaire (HPP) et les cancers sont responsables de 80 à 90 % des causes d’hypercalcémie. L’HPP est la première cause en ambulatoire1. Par contre, l’étiologie néoplasique est la plus fréquente en milieu hospitalier. Les autres causes, moins fréquentes, telles que le surdosage en vitamine D, l’hypercalcémie secondaire à la prise de certains médicaments et l’hypercalcémie hypocalciurique familiale, seront abordées dans cet article. L’hypocalcémie est définie par une calcémie inférieure à 2,2 mmol/l. Les causes les plus fréquentes sont l’hypoparathyroïdie postopératoire qui complique la thyroïdectomie totale dans 1,5 % des cas2, le déficit en vitamine D et l’insuffisance rénale chronique préterminale. Les causes plus rares telles que l’hypoparathyroïdie auto-immune, l’agénésie des parathyroïdes, les pseudohypoparathyroïdies et l’hypomagnésémie seront discutées dans cet article.

Denosumab is a very effective treatment of osteoporosis, easy to use and very well tolerated. Due to some associated risks, a close clinical follow-up is necessary. Before the first injection, it is necessary to correct hypocalcaemia or vitamin D deficiency when present. Calcemia has to be followed in case of renal insufficiency. Injections of denosumab should be done scrupulously every 6 months (± 3 weeks). Discontinuation of denosumab is associated with a severe rebound effect characterized by increased markers of bone remodeling, a rapid decrease of bone density values, and a risk of multiple spontaneous vertebral fractures. The administration of a potent bisphosphonate (zoledronate, alendronate) minimises or avoids this rebound effect.Le dénosumab est un traitement très efficace de l’ostéoporose, simple d’utilisation et très bien toléré. Au vu de certains risques associés, un suivi clinique rapproché est nécessaire. Lors de son initiation, il faut corriger une hypocalcémie ou un déficit en vitamine D. Il faut suivre la calcémie en présence d’une insuffisance rénale. Les injections de dénosumab sont à faire scrupuleusement tous les 6 mois (± 3 semaines). L’arrêt du dénosumab s’accompagne d’un effet rebond sévère, caractérisé par une augmentation des marqueurs du remodelage osseux, une diminution rapide des valeurs de densité osseuse et un risque de fractures vertébrales multiples spontanées. L’administration d’un bisphosphonate puissant (zolédronate, alendronate) permet de pallier cet effet rebond.

Chronic calcipenia related to hypo- and pseudohypoparathyroidism favors trophic complications, especially expressed on the buccal cavity. Correlated with early onset of the disease and imperfect correction of the metabolic disorders, retardation to appearance and implantation of teeth are observed. The buccal signs often are the most immediately visible expression of the disease. They are painful and disabling. Other acute expressions reflect the neuromuscular hyperexcitability related to tetany. Finally, some etiologies determine specific damage, as in Di George's, HDR syndromes or in Albright's osteodystrophia.

Introduction Le transfert du calcium de la mère au nouveau-né est nécessaire pour la constitution de la charpente osseuse. L'hypocalcémie néonatale reste peu documentée en Afrique. En 1993, il a été observé au service de néonatologie du Centre hospitalo-universitaire de Yopougon à Abidjan une proportion d'hypocalcémie asymptomatique de 26.9%. L'objectif de ce travail était de préciser la prévalence de l'hypocalcémie néonatale dans une maternité périphérique de Yopougon et en déterminer les facteurs de risque. Méthodes Une étude transversale a été menée à la formation sanitaire de de Yopougon de février à mai 2012 auprès de 145 parturientes et leurs nouveau-nés. Les caractéristiques des mères et des nouveau-nés ont été recueillies. Les prélèvements de sang maternel et du cordon ont permis le dosage des paramètres du métabolisme phosphocalcique. Une régression linéaire multiple a été faite pour apprécier les éléments de prédilection de la calcémie néonatale. Résultats Les valeurs moyennes étaient de 2,271 mmol/l pour la calcémie, 1,169 mmol/l pour le phosphore, 0,735 mmol/l pour le magnésium et 69 g/l pour les protides totaux chez les mères. La durée moyenne du travail était de 499 minutes. L’âge gestationnel moyen était de 39 semaines. Les constantes anthropométriques et cliniques des nouveau-nés étaient normales. Les paramètres phosphocalciques étaient en moyenne normaux (calcémie = 2,52 mmol/l, phosphorémie = 1,668 mmol/l, magnesémie = 0,777 mmol/l, protidémie = 63 g/l). Six gestantes (4,1%) étaient hypocalcémiques contre 12 nouveau-nés (8,1%). La durée du travail influençait la calcémie néonatale (p = 0,02). En analyse multivariée, 34% de la variabilité de la calcémie néonatale était expliqué par la calcémie maternelle et la durée du travail. Conclusion L'hypocalcémie néonatale est rare en zone tropicale. Dans cette étude, la proportion était de 8,1%. La durée du travail influençait la calcémie néonatale. Aussi, nous recommandons de poursuivre les investigations en dosant, en plus, la vitamine D et le Parathormone de la naissance à J7 de vie et préciser les étiologies de ces hypocalcémies.

Bone is the most common metastatic site. The skeleton is also the preferential initial metastatic site in breast and prostate carcinomas. Objective complications of bone metastases are named « skeletal-related events » (SREs) and generally include the need for radiotherapy on bone, surgery to bone, pathologic fracture and spinal cord compression. Recent phase III double-blind trials have demonstrated the superiority of denosumab to zoledronic acid for delaying the time to first SRE in patients with breast or prostate cancer and bone metastases. Non-inferiority was shown in the trial including other solid tumors and multiple myeloma. The overall burden of the disease was also significantly reduced in the breast and prostate cancer studies, and in the pre-specified integrated analysis that included all three comparative trials. Denosumab is conveniently administered by subcutaneous injections and is devoid of renal toxicity. However, denosumab induces more cases of hypocalcaemia than zoledronate. Calcium and vitamin D supplementation is recommended during therapy and it is advised to regularly monitor calcium levels during denosumab long-term treatment. There are numerically more cases of osteonecrosis of the jaw, but the differences are not statistically significant between zoledronate and denosumab, whether in the individual studies or in the integrated analysis. Treatment with these potent inhibitors of bone resorption should be progressively 'individualized' to better define the place of intermittent treatments, to decrease the occurrence of toxic effects and to improve the cost-effectiveness ratio of new compounds.

Hypocalcemia due to hypoparathyroidism produces a broad spectrum of clinical manifestations, but overt symptoms may be sparse. One unusual presentation is onset or aggravation of epilepsy in adolescence revealing hypoparathyroidism. This situation can lead to delayed diagnosis, with inefficacity of the antiepileptic drugs. We report five cases of adolescence-onset epilepsy with unsuccessful antiepileptic therapy, even with gradually increasing dose. Physical examination revealed signs of hypocalcemia, confirmed biologically. Full testing disclosed the origin of the seizures: hypoparathyroidism in three patients and pseudohypoparathyroidism in the other two. In four of five patients, computed tomography showed calcification of the basal ganglia, defining Fahr's syndrome. The patients were treated with oral calcium and active vitamin D (1-alphahydroxy vitamin D3). Seizure frequency progressively decreased and serum calcium levels returned to normal. These cases illustrate the importance of the physical examination and of routine serum calcium assay in patients with new-onset epileptic seizures in order to detect hypocalcemia secondary to hypoparathyroidism.

The occurrence of electrolyte disorders as hypocalcemia and/or hyponatremia is an uncommon event in preeclampsia, which can be the sign of serious situation, with potentially unfavourable consequences for the mother and her fœtus. Hyponatremia in the setting of preeclampsia is an indicator of severity, and requires the understanding of the etiologic mechanisms to initiate an appropriate treatment. Indeed the often-considered fluid restriction is rarely a treatment option for pregnant women. Hypocalcemia is a complication that must be monitored when a treatment with high doses of intravenous magnesium sulphate is introduced. In this context, hypocalcemia must be sought, with the exclusion of other etiologies as vitamin D deficiency, hypoparathyroidism or renal and extrarenal loss of calcium. A replacement therapy, intravenous or oral according to circumstances, should be considered in case of severe or symptomatic hypocalcemia.

Neonates and infants with hypocalcemia usually present with seizures, whereas this is less common in older children and teenagers. We report on a case of hypocalcemic seizures in a 16-year-old girl with undiagnosed end-stage renal disease with progressive growth retardation and bone deformations. We highlight the value of checking serum calcium, phosphate, and creatinine in children with growth retardation, seizures, and/or unexplained bone deformations. We also discuss the clinical consequences of pediatric renal osteodystrophy.

Congenital hypomagnesemia is a rare disease, with an impact on cognitive and neurological development. We report on three familial cases of congenital hypomagnesemia, two boys and one girl who belong to the same consanguineous family. They all presented neonatal seizures and a psychomotor developmental delay. Cerebral computed tomography showed cerebral atrophy and calcifications in one case and magnetic resonance imaging found predominant cerebellar atrophy in the two other cases. All three patients also had hypocalcemia, hyperphosphoremia, and hypomagnesemia. The parathyroid hormone blood level was low in two cases and normal in the third. One 7-month old patient died. The others received a supplementation of calcium and magnesium, which normalized calcemia, phosphatemia but not magnesemia, which remained low despite high doses. They have both developed cognitive and behavioral impairments.

Hypocalcemia is very rare reversible cause of dilated cardiomyopathy (DCMP) witch can concern one or both ventricules. We here presented two cases of DCMP that caused by hypocalcemia and recovered totally after oral calcium and vitamin D supplementation. CASE PRESENTATION 1: A 29-year-old Caucasian female was admitted in our hospital due to congestive heart failure with dyspnea (NYHA class IV) and generalized edema for 2days. She had a history of total thyroidectomy one year a go. She had taken synthyroid as a daily medication associated to calcium supplementation and vitamin D because of hypoparathyroidism. Patient was not compliant to treatment. Trans thoracic echocardiography (TTE) showed a dilated left ventricule (LV) with global hypokinesia with 28% of left ventricule ejection and moderate mitral regurgitation. Laboratory test showed a severe hypocalcemia. After correction of hypocalcemia, there was a clear clinical improvement and four months later a total recovery was found. CASE PRESENTATION 2: A 44-year-old Caucasian male was referred to the hospital for rebel congestive heart failure with dyspnea and edema of lower limbs despite optimal treatment. Patient had no medical past history. TEE showed dilated cardiomyopathy with severe alteration of left ventricule systolic function (25%). Biological tests showed a hypocalcemia and primary hypoparathyroidism. An improvement of symptoms after correction of metabolic disorder was found. LV gradually recovered its performance.Patients outcome in end stage heart failure is different from the classical outcomes in patients with hypocalcemia induced heart disease. DCMP induced by hypocalcemia should be considered in patients with heart failure associated with medical conditions leading to hypocalcemia. It requires a specific treatment.

Vitamin D plays a key role in calcium-phosphorus homeostasis and bone metabolism, but it is also involved in numerous others tissues. Vitamin D deficiency among pregnant women is frequent in many populations over the world. It is associated with an increased risk of preeclampsia, gestational diabetes mellitus, and caesarean section. Consequences in newborns are low birth weight, neonatal rickets, a risk of neonatal hypocalcemia, asthma and/or type 1 diabetes. Therefore, prevention of vitamin D deficiency among pregnant women is essential. The currently recommended supplementation amount of vitamin D is not sufficient to maintain a value of 25 hydroxy vitamin D above 30 ng/ml, during pregnancy. Randomized controlled trials during pregnancy are necessary to evaluate the amount of vitamin D sufficient to avoid the consequences of vitamin D deficiency.

We report on two patients on chronic hemodialysis, who presented with typical symptoms of hyperkalemia (lower limb paresia and characteristic electrocardiogram [ECG]) for an only mildly increased kalemia (6.1 and 6.2 mEq/L), values that are frequently seen in asymptomatic patients on chronic hemodialysis. Their common denominator was a concomitant hypocalcemia (7.5 et 6.4mg/dL) induced by cinacalcet treatment. Hypocalcemia has very likely precipitated the occurrence of clinical and electrocardiological manifestations of hyperkalemia. This observation is in agreement with previous publications showing that, in other clinical situations than the use of cinacalcet, hypocalcemia potentiates the effect of hyperkalemia on muscle membrane. Nephrologists should be aware of this complication and pay most attention in their patients on chronic dialysis with a calcemia less than 8mg/dL induced by cinacalcet treatment.

A 98-year-old woman was referred to our hospital because of myoclonia. The concentration of calcium and vitamin D in the serum was low. In this context, we concluded of neuromuscular irritability secondary to hypocalcaemia. The symptoms disappeared after a treatment of intravenous calcium. This case shows how important it is to investigate electrolytes in case of neuromuscular irritability symptoms in elderly people.

The recurrential nerve palsy (RNP), the hypocalcemy and bleeding are traditional complications of the thyroid surgery. The objective is to bring back the postoperative rates of complications and to compare them with the patient's history and the goiter features (CT-scan extensions and weight) in order to identify predictive factors of these complications.One hundred and seventeen patients with a goiter below the subclavicular vessels on the cervicothoracic CT-scan and with a benign extemporane histopathology were operated between february 1997 and January 2004 and included in this retrospective study. The initial clinical assessment reports the respiratory and digestive functional signs, researches a palpable mass and studies the mobility of the vocal folds. The post-operative complications rates (RNP hypocalcemy and bleeding) are analyzed according to the patient's history and the goiter extensions in order to correlate these factors with the complications occurence.Five unilateral RNP occurred and two of them remained permanent, particularly for patients with thyroid surgery history (NS). The right/left or anterior/posterior extensions did not seem determining factors. Nevertheless the volume of the goiter suspected by the tracheal latero-deviation seems to play a role but without statistical confirmation. Among the thirty-four hypocalcemies, six were defined like permanent, without correlations with the surgical history nor the systematic identification of parathyroid glands. The volume and the younger age of the patient tend nevertheless to support the hypocalcemy. Three post-operative bleeding cases were reported, which one needed a reoperation, with a correlation with thyroid surgical history. None the factors among volume, extension or the age of the patient seem to play a role.The cervico-thoracic CT-scan is essential since echography does not manage to identify the lower pole of the gland. It helps to define the goiter and to analyze its extensions, very usefull to predict surgical difficulties in the preoperative information of the patient. Complications occurrence seems related on the volume and the thyroid surgical history.