Endocrine Abstracts

A 51 year old female presented with an Adjusted Calcium (Adj Cal) of 1.68mmol/l (Ref: 2.20-2.60 mmol/l), raised PTH 24.2 pmol/l (1.6-6.9 pmol/l) and raised Alkaline phosphatase (ALP). She had a background of type 2 intestinal failure secondary to surgical complications resulting in stoma formation. She reported peri-oral tingling, joint stiffness, cramps and generalised pain over several months which left her requiring the use of a wheelchair for mobilisation. There was proximal myopathy, QT prolongation and Chvostek’s sign was elicited on examination. She was managed with bolus and infusion intravenous 10% calcium gluconate therapy. Blood results showed undetectable Vitamin D for the prior 2 years. Her Adj Cal levels showed a steady decline for the past year with nadir levels on this admission. 300,000 units of intramuscular Vitamin D was administered to bypass gut absorption. along with daily oral calcium (sandocal) and 1-OH vitamin D (alfacalcidol) supplementation. During her admission the patient required daily infusions of 100ml 10% calcium gluconate to keep her adjusted calcium levels >1.9 mmol/l. A spot urine calcium performed excluded pathological loses at the kidney and a DEXA scan showed evidence of osteomalacia with a T score of -3.1 at the femoral neck. A diagnosis of hungry bone syndrome secondary to prolonged Vitamin D deficiency was made. She was discharged on daily calcium infusions and 3 monthly 25-OH vitamin D injections after a 2 month inpatient stay. Management will be guided by her Adj Ca and ALP with repeat DEXA scanning. The patient’s symptoms improved, improving her quality of life and suitability for stoma reversal surgery. We present this case to highlight the consequences of prolonged, severe hypovitaminosis D, the reversibility of the condition and the management of a “hungry bone” case in the absence of preceding parathyroid surgery.