Mood disorder as a manifestation of primary hypoparathyroidism: a case report

R. Hypocalcemia-Induced Reversible Psychosis

Hypocalcemia can manifest as a variety of presentations, ranging from neuromuscular irritability to seizures, and psychiatric manifestations such as emotional instability, anxiety, and depression. Here, we present a unique case of hypocalcemia-induced acute psychosis.

A 24-year-old woman presented to the emergency department (ED) with confusion and agitation for four to five days. The patient was noted by the family to have decreased oral intake and sleep. Auditory and visual hallucinations prompted the family to bring the patient to the ED. The patient was mildly tachycardic. Initially, the patient was agitated, impulsive, and aggressive, exhibiting psychotic features including visual hallucinations, paranoid delusions, thought broadcasting, tangential and perseverative thought processes, and erotomanic delusions. She had mild leukocytosis and elevated procalcitonin on admission. A thorough workup ruled out infectious/inflammatory processes. Cerebrospinal fluid was negative for acute meningitis/encephalitis, autoimmune encephalitis antibodies, and paraneoplastic etiology. Thyroid-stimulating hormone was normal and thyroid antibodies were negative. The CT brain and MRI brain were unremarkable. The patient was severely hypocalcemic (6.7) with low parathyroid hormone (<6) on admission.

To note, the patient has multiple endocrine neoplasia, type 2B (MEN2B). She underwent total thyroidectomy five months prior for metastatic medullary thyroid carcinoma complicated by postsurgical hypoparathyroidism. The patient had been non-compliant with calcium and calcitriol supplementation postoperatively.

The patient was started on IV calcium gluconate and transitioned to calcitriol with calcium level improvement over the next three days. She experienced marked improvement, with the resolution of her psychosis. The patient’s subacute onset psychosis with no personal or family psychiatric history and a rapid response to calcium correction supports hypocalcemia etiology.

This case illustrates new-onset acute psychosis in a patient with calcium regulation imbalance. The development of hypocalcemia secondary to thyroidectomy with postsurgical hypoparathyroidism and calcium supplement non-compliance precipitated psychosis. A few similar cases have been reported, and here, we note that treatment of hypocalcemia promptly resolves symptoms. As per our review, this will be the first case of neuropsychiatric symptoms without associated cortical calcifications seen on imaging. It is important to recognize hypocalcemia as a rare cause of psychosis so as to not mistakenly categorize such presentations as primary psychotic disorders and miss a medically treatable illness.

Intractable hypocalcemic seizures with neuropsychiatric symptoms- An under-diagnosed case

Idiopathic hypoparathyroidism is one of the important and treatable causes of hypocalcaemia. Patients with hypocalcaemia as a consequence of hypoparathyroidism can have varied neuropsychiatric presentations such as intractable seizures, depressive symptoms, psychosis, generalized parasthesias and extrapyramidal syndrome. Many times these patients are being wrongly treated as a case of depression without addressing the underlying cause. We present a case of 26-year-old female patient who presented in emergency with multiple episodes of complex partial seizures since the last 6 months and under the treatment for depression for 2 years. She was diagnosed as a case of hypocalcemia and hypoparathyroidism was considered as the underlying cause.

Effects of Treatment Adherence on Quality of Life in Hypoparathyroid Patients

OBJECTIVES

This study aimed to evaluate the current situation of hypoparathyroid patients and to investigate the relationship between treatment adherence and quality of life.

STUDY DESIGN

Prospective, multicentre study.

METHODS

Adult patients presenting with the diagnosis of hypoparathyroidism to 20 different endocrinology clinics were included. They were receiving conventional therapies for hypoparathyroidism, using calcium, active vitamin D, and magnesium. We collected data on demographic features, disease- and treatment-related information, and results of routine laboratory tests, treatment adherence, and presence of complications. Beck Depression Inventory, Beck Anxiety Inventory, and Short Form-36 quality of life assessments were administered.

RESULTS

Among the 300 patients studied, 60.7% were adherent to their treatment, and 34.1% had complications. Anxiety and depression scores were significantly higher in non-adherent versus treatment-adherent patients (p<0.001 and p=0.001, respectively). Most of the domains of quality-of-life scores were also significantly lower in non-adherent patients. Both anxiety and depression scores showed significant, negative correlations with serum calcium and magnesium concentrations (r=-0.336, p<0.001 and r=-0.258, p<0.001, respectively).

CONCLUSIONS

Nearly 40% of the patients were non-adherent to conventional treatment for hypoparathyroidism, and such patients had higher anxiety and depression scores and poorer quality of life scores. Conventional treatment might not be sufficient to meet the needs of patients with hypoparathyroidism. In addition to seeking new therapeutic options, factors influencing quality of life should also be investigated and strategies to improve treatment adherence should be developed.

A rare case of sever primary hypoparathyroidism presented with amnesia and basal ganglia calcification

Objectives

The aim of this study was to describe clinical findings in a 45-year-old man with history of two sided cataract surgery, convulsions and progressive memory impairment.

Methods

The patient presented to the neurology department because of having progressive memory impairment over the past two years. After taking necessary examinations the patient was referred to the endocrine center because of hypocalcemia in laboratory tests. Brain CT scan and MRI was also done.

Results

Brain CT scan of patient showed extensive and symmetric calcification of basal ganglia, thalami and cerebellum. On Brain MRI, abnormal signal foci in the both sided paraventricular regions, basal ganglia and cerebellar hemisphere were depicted. Laboratory investigations were notable for low serum calcium (5.4 mg/dl, reference range: 8.2-11.2), high serum phosphorus (7.6 mg/dl, reference range: 2.7-4.5), vitamin D deficiency (25-OH D3: 14.5 ng/ml) and low parathyroid hormone (IPTH: 3.7 pg/mL, reference range: 10-62).

Conclusions

This patient presented with amnesia which is a rare presentation of hypoparathyroidism.

Total and ionized calcium and magnesium are significantly lowered in drug-naïve depressed patients: effects of antidepressants and associations with immune activation

Major depressive disorder (MDD) is associated with alterations in calcium (Ca) and magnesium (Mg), as well as circulating pro- and anti-inflammatory cytokines. Anti-inflammatory drugs are commonly used as adjuvant treatments for MDD. However, no studies examined the effects of a combinatorial treatment with sertraline and ketoprofen, an anti-inflammatory drug, on Ca and Mg levels in MDD. The present study examined a) differences in both cations between drug-naïve MDD patients and controls, and b) the effects of sertraline and ketoprofen on Ca and Mg (both total and ionized). In the same patients, we also examined the associations between both cations and IL-1β, IL-4, IL-6, IL-18, IFN-γ, TGF-β1, zinc, and indoleamine 2,3-dioxygenase (IDO). Clinical improvement was assessed using the Beck Depression Inventory-II (BDI-II) at baseline and after follow up for 2 months. Serum Ca and Mg (total and ionized) were significantly lower in MDD patients as compared with controls, while treatment significantly increased calcium but decreased magnesium levels. There were significant and inverse correlations between the BDI-II scores from baseline to endpoint and Ca (both total and ionized), but not Mg, levels. The effects of calcium on the BDI-II score remained significant after considering the effects of zinc, IDO and an immune activation z unit-weighted composite score based on the sum of all cytokines. There was a significant and inverse association between this immune activation index and calcium levels from baseline to endpoint. In conclusion, lowered levels of both cations play a role in the pathophysiology of major depression. Antidepressant-induced increases in Ca are associated with clinical efficacy and attenuation of the immune response. The suppressant effect of antidepressants on Mg levels is probably a side effect of those drugs. New antidepressant treatments should be developed that increase the levels both Ca and Mg. Graphical abstract.

Diagnosis and treatment of hypoparathyroidism: a position statement from the Brazilian Society of Endocrinology and Metabolism

Objective To present an update on the diagnosis and treatment of hypoparathyroidism based on the most recent scientific evidence. Materials and methods The Department of Bone and Mineral Metabolism of the Sociedade Brasileira de Endocrinologia e Metabologia (SBEM; Brazilian Society of Endocrinology and Metabolism) was invited to prepare a document following the rules set by the Guidelines Program of the Associação Médica Brasileira (AMB; Brazilian Medical Association). Relevant papers were retrieved from the databases MEDLINE/PubMed, LILACS, and SciELO, and the evidence derived from each article was classified into recommendation levels according to scientific strength and study type. Conclusion An update on the recent scientific literature addressing hypoparathyroidism is presented to serve as a basis for the diagnosis and treatment of this condition in Brazil.

Relationship between serum calcium and neuropsychological performance might indicate etiological heterogeneity underlying cognitive deficits in schizophrenia and depression

Cognitive dysfunction is a core feature of schizophrenia spectrum and depressive disorders. Influx of extracellular calcium is essential for neuronal processes such as pre-synaptic neurotransmitter release and NMDA receptor mediated neuroplasticity. Since serum and brain interstitial fluids maintain equilibrium for ion concentrations via passive diffusion, the amount of peripheral calcium could affect neuronal and hence cognitive function. Within the physiological norm-levels, we hypothesized higher serum-calcium would be associated with better neuropsychological performance in patients diagnosed with schizophrenia or depression. One-tailed Pearson's correlations were calculated between total serum-calcium levels and performance on an extensive computer-based neuropsychological test battery. Influence of covariates was assessed using linear regression. Serum calcium was significantly and positively correlated with neuropsychological composite, information processing speed, executive function and global assessment of functioning (GAF) in depression patients but not in schizophrenia patients. Amongst covariates, age associated significantly with serum calcium and neuropsychological functioning in depression but only with serum calcium in schizophrenia group. The study provides first evidence for a positive relationship between serum calcium and neuropsychological/daily-life function in depression. Absence of this correlation in schizophrenia could point to etiological heterogeneity concerning calcium-related processes underlying cognitive deficits in these disorders.

Clinical insights by the presence of bipolar disorder in pseudohypoparathyroidism type 1A

Pseudohypoparathyroidism type 1A and its association with bipolar disorder (BD) have never been reported so far. We report a new case with both clinical entities and discuss the potential pathophysiological mechanisms of this association (protein kinase A hypoactivation, parathyroid hormone, hypocalcemia, protein kinase C activation, vitamin D deficiency). In this patient, the correction of the underlying calcium and vitamin D deficiencies leads to a better BD outcome and lower dosage of psychopharmacological agents. The conclusions might be generalized for a better understanding and management of these conditions.