[一名14岁男孩的严重低钙和低镁血症——与无症状乳糜泻相关的治疗困难]。

Wioletta Stacha, Marek Niedziela
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引用次数: 0

摘要

与低镁血症相关的迟发性低钙血症(>3日龄)的存在产生了临床困境。这种疾病的存在可能是由于镁缺乏伴继发性甲状旁腺功能低下、先天性甲状旁腺功能低下(HPT)、磷中毒、钙敏感受体(CASR)激活突变或CASR刺激抗体的存在。磷中毒时,与其他原因相比,血清甲状旁腺激素水平明显升高。钙和磷会竞争肠道吸收,因此如果钙摄入量高,镁的吸收就会减少,反之亦然。患者病史:14岁男孩,几天前因破伤风发作入院。重度低钙血症(1.49 mmol/L)伴低镁血症(13.8 mg/L)、代谢性碱中毒(pH=7.65)和高磷血症(10.5 mg/dL)。该男孩青春期前,甲状腺功能正常,比例小体发育。严重的低血清PTH水平(2 pg/mL)排除磷中毒。单纯镁盐处理(p.o.)不能提高血清镁水平和钙浓度。排除原发性镁缺乏症,因此,钙盐补充和1 α (OH)D3治疗(HPT的典型治疗)联合缓释镁盐开始。治疗的难点在于寻找消化道缺陷,最后根据肌内膜抗体和十二指肠活检证实为乳糜泻。无麸质饮食可显著改善钙磷参数,显示甲状旁腺功能低下的自身免疫性背景非常可能。
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[Severe hypocalcemia and hypomagnesemia in a 14-year-old boy--difficulties in treatment related to silent coeliac disease].

The presence of late-onset hypocalcemia (>3 days of age) associated with hypomagnesemia generates a clinical dilemma. Such a disorder may exist as a result of magnesium deficiency with a secondary hypoparathyroidism, congenital hypoparathyroidism (HPT), phosphorus intoxication, activated mutation of calcium sensing receptor (CASR) or the presence of CASR stimulatory antibodies. In phosphorus intoxication, in contrast to the other reasons, serum PTH level is rather elevated. Calcium and phosphorus compete for intestinal absorption and thus if calcium intake is high then magnesium absorption is reduced and vice versa. Patient's history: 14-year-old boy was admitted to the ward because of tetanic seizure few days before. Severe hypocalcemia (1.49 mmol/L) with hypomagnesemia (13.8 mg/L) as well as metabolic alkalosis pH=7.65) and high phosphorus level (10.5 mg/dL) were noted. The boy was prepubertal, euthyroid and proportionally microsomic. Severely low serum PTH level (2 pg/mL) excluded phosphorus intoxication. Magnesium salts treatment alone (p.o.) was introduced but this treatment did not improve serum magnesium level as well as calcium concentration. Primary magnesium deficiency was excluded and therefore calcium salts supplementation and 1alpha(OH)D3 therapy, typical for HPT, was initiated combined with slow-released magnesium salts. Difficulties in the treatment tended to look for the digestive tract defects and finally, based on endomysial antibodies and duodenal biopsy the coeliac disease was confirmed. With gluten-free diet the significant improvement of calcium-phosphorus parameters has been observed showing that the autoimmune background of hypoparathyroidism is very likely.

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