Calcium levels (decrease/increase) in hypoparathyroidism.
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A 16-year-old girl comes to the emergency department because of a panic attack. She began feeling tingling around her mouth and then became nervous at this symptom, causing her to hyperventilate. The tingling has persisted, and she also reports having had muscle cramps and spasms for the past week. A metabolic panel reveals normal electrolytes except for a low serum calcium. A review of the patient's chart reveals thyroid surgery one month earlier due to a suspicious nodule. Which of the following findings is most likely to also be present in this patient?
With hypoparathyroidism, “hypo” refers to under, and “parathyroid” refers to the parathyroid glands, so hypoparathyroidism refers to a condition where there is an underproduction of parathyroid hormone.
Parathyroid hormone comes from the parathyroid glands which are buried within the thyroid gland, and their main job is to keep blood calcium levels stable.
Now, the majority of the extracellular calcium, the calcium in the blood and interstitium, is split almost equally between two groups - calcium that is diffusible and calcium that is not diffusible.
Diffusible calcium is small enough to diffuse across cell membranes and is separated into two subcategories.
The first is free-ionized calcium, which is involved in all sorts of cellular processes like neuronal action potentials, contraction of skeletal, smooth, and cardiac muscle, hormone secretion, and blood coagulation, all of which are tightly regulated by enzymes and hormones.
The second category is complexed calcium, which is where the positively charged calcium is ionically linked to tiny negatively charged molecules like oxalate, which is a small anion that are normally found in our blood in small amounts.
The complexed calcium forms a molecule that’s electrically neutral but unlike free-ionized calcium it’s not useful for cellular processes.
Both of these are called diffusible because they’re small enough to diffuse across cell membranes.
Finally there’s the non-diffusible calcium which is bound to negatively charged proteins like albumin.
The resulting protein-calcium complex is too large and charged to cross membranes, leaving this calcium also uninvolved in cellular processes.
Changes in the body’s levels of extracellular calcium are detected by a surface receptor in parathyroid cells that’s called the calcium-sensing receptor.
These changes affect the amount of parathyroid hormone that’s released by the parathyroid gland.
The parathyroid hormone gets the bones to release calcium, it gets the kidneys to reabsorb more calcium so it's not lost in the urine, and it synthesizes calcitriol, which is also known as 1,25-dihydroxycholecalciferol, or active Vitamin D.
Altogether, these effects help to keep the extracellular levels of calcium within a narrow range that’s between 8.5 to 10 mg/dl.
The most common cause of hypoparathyroidism is removal of the parathyroid glands during thyroid or parathyroid surgery.
Another cause includes autoimmune polyendocrine syndrome type 1 which destroys parathyroid glands.