Two Different Causes of Paediatric Hypercalcaemia

Efficacy of denosumab therapy for a 12-year-old female patient with Williams syndrome with osteoporosis and history of fractures: a case report

Background

A decrease in bone mineral density is common in patients with Williams syndrome. However, appropriate management for osteoporosis in Williams syndrome patients has not been established. We report the case of a 12-year-old female patient with Williams syndrome, who underwent denosumab treatment for osteoporosis.

Case presentation

A 12-year-old Japanese female patient with Williams syndrome was shown to have very low bone mineral density. Bone mineral density was evaluated before treatment and at 5, 9, 17, 23, and 29 months of treatment by dual-energy X-ray absorptiometry. After denosumab therapy for 29 months, lumbar and total hip bone mineral density values had increased by 51.6% and 37.6%, respectively. No new fractures occurred during the observation period.

Conclusions

To the best of our knowledge, this is the first experience with denosumab treatment in Williams syndrome patients with osteoporosis. Based on our findings, denosumab may be an effective treatment option for Williams syndrome patients with osteoporosis.

Primary Hyperparathyroidism as a Rare Cause of Unexplained Recurrent Abdominal Pain: Case Presentation and Literature Review

Abdominal pain is a common symptom in surgical practice. Around 11%-45% of pediatric population present with abdominal pain. In 29%-87.5% of pediatric population diagnosed with primary hyperparathyroidism (PHPT), abdominal pain and other gastrointestinal (GI) symptoms were the presenting complaint. Hyperparathyroidism is a condition characterized by increased parathyroid hormone (PTH) secretion. It usually presents with nonspecific symptoms of fatigue, poor appetite, weight loss, abdominal pain, nausea, emesis, and bone pain.

We present a case of a 13-year-old girl who experienced a recurrent abdominal pain associated with nausea and vomiting, which was diagnosed eight months later when her laboratory investigation revealed high amylase, calcium, and PTH, which raised a suspicion of pancreatitis secondary to hyperparathyroidism. Imaging studies showed retrosternal lesion within the thymus gland, most likely a thymic parathyroid adenoma. The patient's symptoms resolved following thoracoscopic thymectomy, which was performed in another center.

To assess the relationship between GI symptoms and PHPT, we reviewed 13 articles published between 2007 and 2020 in the English literature which reported 331 cases of primary PHPT and found that GI symptoms are the fourth most common presentation in patients with PHPT. In those patients, the reported incidence of GI symptoms including abdominal pain was 18.67%. Out of the 331 cases included, only one case mimicked our case as abdominal pain was the main presenting symptom.

Unexplained recurrent abdominal pain should raise the suspicion for rare causes. Hyperparathyroidism should be included in the differential diagnosis of recurrent abdominal pain.

Nationwide questionnaire data of 229 Williams-Beuren syndrome patients using WhatsApp tool

BACKGROUND

Williams-Beuren syndrome is a multisystemic disorder caused by a microdeletion of the 7q11.23 region. Although familial cases with autosomal dominant inheritance have been reported, the vast majority are sporadic.

OBJECTIVE

To investigate the main complaints and clinical findings of patients with Williams-Beuren syndrome.

METHODS

A total of 757 parents of patients registered in the Brazilian Association of Williams-Beuren Syndrome (ABSW) received a questionnaire via WhatsApp from March to July 2017.

RESULTS

In total, 229 parents answered the survey. Age of diagnosis ranged from 2 days to 34 years (median: 3 years). The main clinical findings reported by the parents were abdominal colic (83.3%), failure to thrive (71.5%), feeding difficulty in the first year (68.9%), otitis (56.6%), urinary tract infections (31.9%), precocious puberty (27.1%) and scoliosis (15.9%). Cardiac defects were present in 66% of patients, and the most frequent defect was supravalvular aortic stenosis (36%). Arterial hypertension was reported in 23%. Hypercalcemia was reported in 10.5% of patients, mainly during the first year of life. Hyperacusis and hypersociability were common complaints (both present in 89%). Other behavioral and neuropsychiatric symptoms reported by the parents included attention deficit (89%), anger crises (83%), excessive fear (66%), depression (64%), anxiety (67%) and hypersexuality (33%). The most common complaints were hypersensitivity to sounds, talkative personality, emotional dependence and learning difficulties. In 98.3%, the parents denied family history.

CONCLUSIONS

Williams-Beuren syndrome requires close follow-up with different medical specialties due to their variable clinical comorbidities, including language and school learning difficulties, behavioral and psychiatric problems.

To be, or not to be… Guillain-Barré Syndrome

Guillain-Barré Syndrome (GBS) is currently the most frequent cause of acute flaccid paralysis on a global scale, being an autoimmune disorder wherein demyelination of the peripheral nerves occurs. Its main clinical features are a symmetrical ascending muscle weakness with reduced osteotendinous reflexes and variable sensory involvement. GBS most commonly occurs after an infection, especially viral (including COVID-19), but may also transpire after immunization with certain vaccines or in the development of specific malignancies. Immunoglobulins, plasmapheresis, and glucocorticoids represent the principal treatment modalities, however patients with severe disease progression may require supportive therapy in an intensive care unit. Due to its symptomology, which overlaps with numerous neurological and infectious illnesses, the diagnosis of GBS may often be misattributed to pathologies that are essentially different from this syndrome. Moreover, many of these require specific treatment methods distinct to those recommended for GBS, in lack of which the prognosis of the patient is drastically affected. Such diseases include exposure to toxins either environmental or foodborne, central nervous system infections, metabolic or serum ion alterations, demyelinating pathologies, or even conditions amenable to neurosurgical intervention. This extensive narrative review aims to systematically and comprehensively tackle the most notable and challenging differential diagnoses of GBS, emphasizing on the clinical discrepancies between the diseases, the appropriate paraclinical investigations, and suitable management indications.