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Okuno F, Ito-Masui A, Hane A, Maeyama K, Ikejiri K, Ishikura K, Yanagisawa M, Dohi K, Suzuki K. Severe hypocalcemia after denosumab treatment leading to refractory ventricular tachycardia and veno-arterial extracorporeal membrane oxygenation support: a case report. Int J Emerg Med 2023; 16:52. [PMID: 37635211 PMCID: PMC10463425 DOI: 10.1186/s12245-023-00529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Severe hypocalcemia may lead to life-threatening arrhythmias. Denosumab is an effective treatment for osteoporosis that allows long intervals between doses. However, there is a risk of hypocalcemia in some patients. Due to the long half-life of denosumab, emergency physicians caring for patients presenting with symptoms of hypocalcemia may not be aware of the medication, and adverse effects may last longer. CASE PRESENTATION A 55-year-old woman with a history of systemic lupus erythematosus (SLE) and anxiety disorder called for an ambulance for symptoms of hyperventilation and muscle cramps. After evaluation at the local hospital, she developed pulseless ventricular tachycardia and was resuscitated by defibrillation by the hospital staff. After conversion to sinus rhythm, she was transported to a tertiary center. Upon arrival, pulseless ventricular tachycardia occurred again, and veno-arterial extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) were implemented. Laboratory results showed severe hypocalcemia (corrected calcium level of 5.3 mg/dL) whereupon intravenous calcium supplementation was started. She had received the first dose of denosumab (60 mg) by subcutaneous injection 24 days prior to hospitalization. She was eventually weaned from ECMO and IABP support. CONCLUSION Cardiac arrest due to hypocalcemia is relatively rare but can be fatal. In the present case, hyperventilation may have acutely exacerbated pre-existing hypocalcemia, leading to ventricular tachycardia. The patient had a slightly decreased serum calcium level prior to denosumab. Close monitoring may be preferable after the primary dose of denosumab in selected patients. Emergency physicians caring for patients who may be suffering from symptoms/signs of hypocalcemia must be mindful of medications that have long half-lives and affect electrolyte balance when treating fatal arrhythmia due to hypocalcemia.
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Affiliation(s)
- Fumito Okuno
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Asami Ito-Masui
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan.
| | - Atsuya Hane
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Keiko Maeyama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Kaoru Ikejiri
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Ken Ishikura
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Masashi Yanagisawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
| | - Kei Suzuki
- Emergency and Critical Care Center, Mie University Hospital, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan
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