Endocrine Abstracts

We present a case of 18 Year male with autoimmune polyendocrine syndrome who presented with seizures to A and E presumed secondary to his profound severe hypocalcemia. Adjusted calcium levels of 1.80 mmol/l.

Background: Primary adrenal insufficiency, Hypoparathyroidism, Pancreatic insufficiency and malabsorption, Pernicious anaemia, Aspergers syndrome and Stem cell deficiency in the eye. On admission he received calcium gluconate stat doses which was followed by calcium carbonate infusion. Following that he stayed in hospital for a few weeks and his calcium was monitored regularly and on several occasions the calcium was critically low requiring infusions. Of note is that his calcium supplements (calcichew were increased to two tablets TDS) and alfacalcidol dose was increased to 2.5 micrograms. Despite increase in the dose his calcium levels were erratic. Due to his pancreatic insufficiency his Creon dose was increased as well. He denied any loose or clay coloured stools, increased stool frequency. Compliance was explored and directly observed treatment was practiced but calcium levels stayed erratic. His calcichew was changed to calcichew forte and dose was increased to 2 tablets QDS and his alfacalcidol dose was increased to 2.75 micrograms and he was discharged when calcium was low normal consistently for a few days off infusion and calcium gluconate. He remained seizure free despite very low calcium levels and had no ECG changes He was discharged from hospital but his follow up blood tests at MSDEC showed very low calcium levels, warranting infusions. (1.84 mmol/l, 1.79, 1.92) and on one occasion he had adjusted calcium of 1.64 mmol/l requiring hospital admission.

Other tests: fecal calprotectin negative

Celiac antibodies negative

Magnesium normal on all occasions (>0.7 mmol/l)

PTH in october 0.8 pmol/L, Vitamin B12 and Folate in range

Vitamin D 16.5

An OGD is requested to look for oesophageal candidiasis his calcichew is switched to calvive tablets. Timing of his Creon tablets is also changed to ensure there was an hour gap between Creon and his calcium supplements.

Discussion: 1. Is there a role of Recombinant parathyroid hormone in these patients?2. Family queried regarding PTH pumps, can this be a potential option in the future?3. If hypocalcemia persists, is there a scope of increasing alfacalcidol further or calvive should be increased?4. How frequently should his calcium levels be monitored