Bullous skin reaction seen after extravasation of calcium gluconate

Compartment Syndrome Secondary to Calcium Gluconate Extravasation

This case report highlights a rare yet severe complication of calcium gluconate extravasation, namely, compartment syndrome. We present the case of an 86-year-old female who developed compartment syndrome following an extravasation of intravenously administered calcium gluconate for the management of hyperkalemia. Initially, mild erythema and edema were observed at the site of extravasation, which eventually progressed to severe pain, a reduction in the joint range of motion due to increased compartment pressure. Despite undergoing a series of fasciotomies, the patient's condition did not improve, and extensive tissue necrosis and gangrene necessitated amputation. This case emphasizes that calcium gluconate extravasation can lead to life-threatening complications, such as compartment syndrome, underscoring the critical importance of employing proper infusion techniques.

A Case of Severe Neonatal Hypocalcemia Treated With Continuous Enteral Calcium

Background/Objective

Hypocalcemia is a common, treatable cause of neonatal seizures. The rapid repletion of calcium is essential for restoring normal calcium homeostasis and resolving seizure activity. The accepted approach to administer calcium to a hypocalcemic newborn is via peripheral or central intravenous (IV) access.

Case Report

We discuss a case of a 2-week-old infant who presented with hypocalcemia and status epilepticus. The etiology was determined to be neonatal hypoparathyroidism secondary to maternal hyperparathyroidism. Following an initial dose of IV calcium gluconate, the seizure activity abated. However, stable peripheral intravenous access could not be maintained. After weighing the risks and benefits of placing a central venous line for calcium replacement, it was decided to use continuous nasogastric calcium carbonate at a rate of 125 mg of elemental calcium/kg/d. Ionized calcium levels were used to guide the course of the therapy. The infant remained seizure-free and was discharged on day 5 on a treatment regimen that included elemental calcium carbonate, calcitriol, and cholecalciferol. He remained seizure free since discharge and all medications were discontinued by 8 weeks of age.

Discussion

Continuous enteral calcium is an effective alternate therapy for restoration of calcium homeostasis in a neonate presenting with hypocalcemic seizures in the intensive care unit (ICU).

Conclusion

We propose that continuous enteral calcium be considered as an alternative approach for calcium repletion in neonatal hypocalcemic seizures, one that avoids the potential complications of peripheral or central IV calcium administration.

Calcinosis Cutis as an Unsuspecting Complication of Hyperkalemia Treatment

Calcinosis cutis is a known but rare complication from the extravasation of intravenous calcium preparations. Calcium gluconate is a commonly used medication to prevent cardiac arrhythmias in the setting of hyperkalemia and cardiac arrest during resuscitation and life support. Extravasation of calcium gluconate may result in skin necrosis and a bullous reaction in its most severe form, which should be promptly recognized so that treatment can be provided. Pediatric patients are more susceptible to this caustic effect while cases in adults are rare. We report the case of a patient who developed bullous skin lesions with skin necrosis and eschar formation after receiving intravenous calcium gluconate for the treatment of hyperkalemia. The patient required an extensive hospital stay and multiple surgical interventions. This case demonstrates that common medications such as calcium gluconate can lead to significant adverse effects that can be mitigated with proper administration and appropriate education about adverse events.

Familial Vitamin D-dependent rickets Type 2A: A report of two cases with alopecia and oral manifestations

Rickets is a metabolic bone disease that develops as a result of inadequate mineralization of growing bone due to disruption of calcium, phosphorus and/or Vitamin D metabolism. In addition, several rare genetic causes of rickets have also been described, which can be divided into two groups. The first group consists of genetic disorders of Vitamin D biosynthesis and action, such as Vitamin D-dependent rickets Type 1A, Type 1B, Type 2A (VDDR2A) and Type 2B. The second group involves genetic disorders of excessive renal phosphate loss (hereditary hypophosphatemic rickets). VDDR2A is a rare autosomal recessive disorder caused by mutation in the Vitamin D receptor gene, leading to end-organ resistance to 1,25(OH)₂ Vitamin D₃. It clinically represents growth retardation presenting in the 1^st year of life and frequently associated with alopecia totalis, which differentiates it from VDDR Type 1. Due to target organ resistance, its response to Vitamin D is poor. We report two cases of familial VDDR2A, with alopecia and oral manifestations.

Genetic Causes of Rickets

Rickets is a metabolic bone disease that develops as a result of inadequate mineralization of growing bone due to disruption of calcium, phosphorus and/or vitamin D metabolism. Nutritional rickets remains a significant child health problem in developing countries. In addition, several rare genetic causes of rickets have also been described, which can be divided into two groups. The first group consists of genetic disorders of vitamin D biosynthesis and action, such as vitamin D-dependent rickets type 1A (VDDR1A), vitamin D-dependent rickets type 1B (VDDR1B), vitamin D-dependent rickets type 2A (VDDR2A), and vitamin D-dependent rickets type 2B (VDDR2B). The second group involves genetic disorders of excessive renal phosphate loss (hereditary hypophosphatemic rickets) due to impairment in renal tubular phosphate reabsorption as a result of FGF23-related or FGF23-independent causes. In this review, we focus on clinical, laboratory and genetic characteristics of various types of hereditary rickets as well as differential diagnosis and treatment approaches.

Successful intermittent intravenous calcium treatment via the peripheral route in a patient with hereditary vitamin D-resistant rickets and alopecia

BACKGROUND

Hereditary vitamin D-resistant rickets (HVDRR) is a rare genetic disorder caused by mutations in the vitamin D receptor (VDR) gene, which result in end-organ resistance to 1,25-(OH)2D3. PATIENTs with HVDRR are mostly treated using i.v. calcium therapy with a central catheter. However, central catheter-related complications have been reported.

PATIENT

The patient was a 3-year-old boy presenting with waddling gait and alopecia. He had hypocalcemia [8 mg/dl (2 mmol/l)], hyperparathyroidism (1,232 ng/l), and elevated 1,25-(OH)2D3 levels (>250 pmol/l). DNA sequence analyses of the VDR gene showed a homozygous C-T transition at codon 152, resulting in a non-sense mutation in exon 5.

INTERVENTIONS AND OUTCOMES

The patient was initially treated with calcitriol (80 ng/kg/day) and high-dose oral calcium (150 mg/kg/day) for one year. At the end of the first year, intermittent (5 days per month) i.v. calcium therapy without a central catheter was initiated because of insufficient clinical and radiological improvement. After 2 years of intermittent i.v. calcium therapy, there was a clear improvement based on clinical progress and on X-ray and biochemical findings. No peripheral complications were reported either.

CONCLUSION

HVDRR with a non-sense mutation in the ligand-binding domain and alopecia was successfully treated with intermittent i.v. calcium without a central catheter.