By Mahmoud Gaber

1. Case presentation By MahmoudGaber

2. Personal history : Mrs Safia A. Mohamed 55 yrs old widow housewife have 8 offsprings from Juhina. Pt is post-menopausal for 10 yrs

3. Complaint : • Neck swelling of 8 yrs duration. • Recurrent episodes of abdominal pain & diarrhea of 5 yrs duration. • Recurrent episodes of abnormal movements of hands & feet of 4 yrs duration.

4. History of present illness : • The condition started by painless swelling in front of the neck of gradual onset, progressive course of 8 yrs duration which reach large size over one year. • dyspnea G II of gradual onset progress to G III over 6 month, no orthopnea or PND of 7 yrs duration. • No chest pain, palpitation, cough or wheezes.

5. Pt sought medical advice and told that she had thyroid swelling in need for thyroidectomy which was done 7 yrs ago. • Replacement therapy was initiated for 3 m then pt stopped it by herself. • 1 yr later, pt experienced general malaise, lack of energy and increased tendency to sleep , all of them were of slowly progressive course

6. 3 yrs later, there were episodes of diffuse colicky abdominal pain of intermittent course for 5-7 days every few months accompanied with diarrhea and fever, diarrhea was more than 6 times daily, loose stool not containing blood or mucus and fever was associated with rigors and sweating. Not usually associated with vomiting. • These episodes occurred more frequently in last 2 yrs. • No constipation or dysphagia.

7. Last 3 yrs, there were episodes of carpopedal spasm for hours accompanied by numbness of face and extremities which improved by calcium tab. as prescribed by a physician. But Pt discontinued ttt. • These symptoms are recurrent and usually occur few days after onset of diarrhea. • No history of convulsion or loss of consciousness.

8. Abdominal enlargement of gradual onset, progressive course of 2 yrs. • Painless bilat. LL swelling of gradual onset, intermittent course of 1 m duration. • History of fracture of Lt thumb after falling on hand 3 yrs ago and fracture of Rt arm after trivial trauma 1 yr ago.

9. No symptoms suggesting urinary system affection. • Pt didn’t noticed change of body weight, change of colour of sclera or skin. • No bleeding tendency. • Pt sought medical advice and received eltroxin 50 once daily & Calcium supplementation in last 2 months after lab. invest.

10. 2 weeks ago, Pt admitted to our hospital presented by carpopedal spasm preceeded by diarrhea, abd. colic and fever for few days before admission. Bl. trasfusion was done 5 days ago. • Pt is not known to be diabetic or hypertensive.

11. Past history : • No PH of surgical operations. • No PH of Bl. transfusion. • No PH of bilharzisis or T.B.

12. Family history : • Her mother suffered from chronic chest disease. • No FH of liver disease or malignancy. • No FH of diabetes or HTN.

13. Examination • Patient looks ill, conscious, alert, comfortable in bed with average body built and stature with coarse features. • Vital signs: • Pulse 90 b/m regular, average volume, equal, no special character, normal v. wall • Bl. P 130/80 mmHg • Temp. 37 degree chart 37.3 to 39 without circadian rhythm • Resp. rate 16 c/m

14. Head & neck • Marked pallor. • Puffy eyelids. • No jaundice. • There is thyroidectomy scar (healed by 1ry intention) • No lymph node enlargement. • No raised JVP • Bilateral cataract

15. Upper limb: • Coarse dry skin • Marked pallor • No clubbing • No spider navi. • Bilateral axillary lymph nodes enlagement discrete , mobile, firm, not tender Rt side 2 LNs 1х1cm of medial group Lt side 2 LNs one 1х1cm in apical group & the other 1х2 cm of medial group)

16. Epitrochlear LNs not palpable. • No tremors. • Lt thumb show fixed extension deformity. • Lt ring finger show flexion deformity of DIP joint

17. lower limbs : • Bilateral LL oedema, symmetrical, pitting, not tender up to knee • Bilateral enlarged inguinal LNs (same criteria) • Rt. side one LN 1.5 х1 cm • Lt side two LNs 1.5 х1cm • No varicose veins

18. Cardiac & Chest examination NAD

19. Abdominal examination: • Inspection • Diffuse abd. enlargement. • Obtuse subcostal angle. • Divercation of recti. • Umblicus : flat, shifted downword. • Intact hernial orifices • Striae albicans

20. Superficial palpation No hotness, no tenderness, no rigidity or superficial masses.

21. Deep palpation • Liver • Rt lobe: 3 f below costal margin, firm in consistency, smooth surface, rounded border, not tender, not pulsating. • Lt lobe : 1 f below handbreadth of same criteria. • Spleen size is more than handbreadth below costal, margin,firm in consistency, smooth surface, preserved notch.

22. Percussion • Upper border of liver at 5th intercostal space at midclav. line • Abd is resonant. • AucultationNAD

23. Neurological ex. : • NAD except for areflexia for deep reflexes

24. Investigations • Laboratory: • Thyroid function tests : • TSH 20.28 mIU/L at 30/10/2012 • At 13/12/2012 • T3 < 25 ng/dL (60 – 175 ng/dL) • T4 5.4 μg/dL (5.5 – 12.3 μg/dL) • TSH 6.06 mIU/L (0.5 – 5.5 mIU/L)

25. CBC neutrophils 74% lymph. 20%

26. ESR: 1st h ------ 112 2nd h ------ 135 • PT 13 min. PC 77 % INR 1.18

27. Chemistry:

28. Electrolytes :

29. Urine analysis: • Alb. trace • Pus cells 3-5 • Uric acid ++ • Stool analysis: • Undigested food ++

30. LDH2196 IU/L (N. 250 - 460) • Uric acid3.5 mg/dl (N. 1.5 - 6 ) • Malta & Widal tests---- negative except S.typhi H positive (1/80). • Anti HCV & Hbs Ag negative • Coombs test: Dir. & ind.negative

31. Radiology • Abd U/S : • liver : moderate enlargement, smooth surface, bright echopattern. • Spleen :moderate to marked enlargement. • G.B. : mild thick wall, multiple small stones • Minimal amount of ascitis. • Well defined hypoechoic area 2.5 cm at portahepatis mostly LN.

32. Echocardiography : normal except for mild mitral regurge & minimal pericardial effusion. • ECG : prolonged QT interval.

33. Bone marrow : ??

34. D.D.

36. Hypocalcemia: causes • Primary Hypoparathyroidism • Surgical,total or partial thyroidectomy and or parathyoidectomy • Autoimmune • Magnesium deficiency;it is important for PTH secretion • PTH resistance (pseudohypoparathyroism) • Vitamin D deficiency • Vitamin D resistance • Other: renal failure, pancreatitis

37. Hypocalcemia • clinical manifestations • Paresthesias • Tetany (carpopedal spasm) • Trousseau’s, Chvostek’s signs (latent tetany) • Seizures • Crampy abdominal pain • Chronic: cataract

38. carpopedal spasm

39. Trousseau’s sign

40. Hypocalcemia: Teatment • Acute • IV calcium infusion • 1-2 gm Ca gluconate (10-20 ml) IV over 10 min • 6 gm Ca gluconate/500 cc D5 over 6 hr • Follow plasma Ca & P Q 4-6 hr & adjust rate • IV or oral calcitriol 0.25-2 mcg/day • Oral calcium carbonate 1-2 gm BID-TID

41. Chronic • Oral calcitriol 0.25-2 mcg/day • Calcium carbonate 1-2 gm BID-TID

42. Tumor lysis syndrome • TLS is a group of metabolic complications that can occur after treatment of cancer, usually lymphomas and leukemias, and sometimes even without treatment. These complications are caused by the break-down products of dying cancer cells and include hyperkalemia, hyperphosphatemia, hyperuricemia, hyperuricosuria, hypocalcemia, and consequent acute uric acid nephropathy and acute renal failure.