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Hypocalcemia usually manifests itself in mild forms associated with vitamin D deficiency, hypomagnesemia, renal failure or induced by bisphosphonates.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> Severe hypocalcemia is very rare, being usually associated with the presence of osteoblastic metastases of breast and, especially, prostate cancer.We report the case of an 84-year-old patient with a history of hypertension, prostatic hypertrophy and heart failure of valvular aetiology with severe systolic dysfunction. The patient received regular treatment with torasemide 5mg, ramipril 2.5mg, acetylsalicylic acid 100mg, carvedilol 6.25mg and dutasteride+tamsulosin. Admitted in Internal Medicine due to a heart failure exacerbation, initiating treatment with intravenous furosemide. Systematic lab tests showed a significant hypocalcemia (corrected calcium 5.2mg/dl; NV 8.1–10.4) with high phosphorus (8.6mg/dl; NV 2–5) normal magnesium (2mg/dl; NV 1.6–2.6), along with a marked elevation of alkaline phosphatase (AP 8.050U/l; NV 40–117 and prostate specific antigen (PSA) 526ng/ml; NV less than 4); normocytic anaemia was also evident (Hb 9.1g/dl, MCV 89fl), low albumin (26g/l, NV 34–48) and impaired renal function (creatinine 1.26mg/dl, estimated glomerular filtration rate 52ml/min/1.73m2). The complementary lab study showed high levels of parathyroid hormone (PTH 91.2pg/ml; NV 14–72), 25-hydroxyvitamin D deficiency (19.1ng/ml; NV 30–100) with normal values of 1,25-dihydroxyvitamin D (76.4pg/ml; NV 26.1–86.5). Venous blood gases and levels of ferritin, folate and vitamin B12 were normal, and negative for transglutaminase antibodies.The patient reported a general syndrome with loss of 8kg plus lumbago, muscle weakness, and paresthesias in acral areas. Trousseau and Chvostek signs were negative. The ECG showed a prolonged QTc interval (549ms). Thoracoabdominal CT showed extensive infiltration of the whole skeleton at the expense of many blastic metastases, and a heterogeneous prostate gland. Bone scintigraphy showed radiotracer hyperfixation throughout the whole skeleton. Oral intake of calcium was initiated (calcium carbonate 3g/day), intravenous calcium infusion (calcium gluconate 736mg/day) and calcitriol (1μg/day). After evaluation by Urology and with the clinical diagnosis of metastatic prostate adenocarcinoma, treatment was initiated with bicalutamide and leuprolide. Within 20 days from the start of treatment, lab results showed persistence of hypocalcemia (calcium corrected 7.7mg/dl), normalization of phosphorus values (3.8mg/dl), PTH close to normal (74pg/ml), with marked decrease of AP (5.086mg/dl) and PSA (281mg/dl). Given the hypocalcemia treatment resistance, the dose of calcium and calcitriol was progressively increased up to 6g of oral calcium, 1472mg of intravenous calcium (1mg/kg/h) and 2.5μg of calcitriol, achieving normal calcium levels after 25 days of treatment. During hospitalization, the patient had an episode of atrial flutter and another of atrial fibrillation. He died a month after admission from respiratory failure in relation to a worsening of his congestive heart failure.Hypocalcemia associated with malignancy is caused by an imbalance between bone formation and resorption, with stimulus of the first one. Excessive osteoclast activity produces a massive deposition of calcium in the newly formed bone; low levels of calcium stimulate PTH secretion, generating a secondary hyperparathyroidism.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> The usual lab test profile is low calcium in blood and urine, hyperparathyroidism and elevated bone resorption markers, such as AP.<a class="elsevierStyleCrossRefs" href="#bib0040">3–5</a> The treatment consists of high doses of oral calcium (1–2g/day), intravenous calcium (0.5–1.5mg/kg/h) and oral calcitriol (0.5–3μg/day) plus antitumor treatment.<a class="elsevierStyleCrossRefs" href="#bib0040">3,5</a> The androgen deprivation therapy helps to reduce disease activity, inducing a decrease of calcium deposition in the bone, which contributes to the correction of hypocalcemia.The case reported corresponds to severe hypocalcemia associated with secondary hyperparathyroidism, in a patient with multiple osteoblastic metastases due to prostate adenocarcinoma. High doses of calcium and calcitriol were required for its correction in addition to hormone-blocking treatment for almost a month." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Diéguez Felechosa M, Noval Menéndez J, Manjón Miguelez L. Hipocalcemia intensa por metástasis osteoblásticas de adenocarcinoma de próstata. Med Clin (Barc). 2017;148:287–288." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypocalcemia in malignancy – unexpected but common" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B. Diniotis" 1 => "E. Sternberg" 2 => "S. Shakuntala" 3 => "M. Chiha" 4 => "P. Khosla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7759/cureus.442" "Revista" => array:5 [ "tituloSerie" => "Cureus" "fecha" => "2015" "volumen" => "7" "paginaInicial" => "e442" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26858923" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypocalcemia with osteoblastic metastases in patient with prostate carcinoma. A cause of secondary hyperparathyroidism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.C. Smallridge" 1 => "H.L. Wray" 2 => "M. Schaaf" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "1981" "volumen" => "71" "paginaInicial" => "184" "paginaFinal" => "188" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7246580" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hungry bone syndrome: persistent hypocalcemia related to osteoblastic bone metastases of prostate cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.A. Riveros" 1 => "L.O. Almodóvar" 2 => "C.F. Danés" 3 => "J.P. Domingo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/jpm.2013.0389" "Revista" => array:6 [ "tituloSerie" => "J Palliat Med" "fecha" => "2013" "volumen" => "16" "paginaInicial" => "1496" "paginaFinal" => "1497" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24160743" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Refractory hypocalcaemia complicating metastatic prostatic carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Rizzo" 1 => "S. Vella" 2 => "M.J. Cachia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2015" "paginaInicial" => "2015" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe hypocalcaemia associated with extensive osteoblastic metastases in a patient with prostate cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.I. Fokkema" 1 => "L.J. de Heide" 2 => "W.D. van Schelven" 3 => "N.A. Hamdy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neth J Med" "fecha" => "2005" "volumen" => "63" "paginaInicial" => "34" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15719851" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014800000006/v1_201704120030/S2387020617301900/v1_201704120030/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014800000006/v1_201704120030/S2387020617301900/v1_201704120030/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617301900?idApp=UINPBA00004N"]

ISSN: 2387-0206

Launched in 1943, Medicina Clínica is a fortnightly journal aimed at the promotion of clinical research and practice among internal medicine and other specialists. The key characteristics of Medicina Clínica are the scientific and methodological rigor of its manuscripts, the topicality of its contents, and, especially, its practical focus with highly useful information for clinical practice. Medicina Clínica is predominantly interested in publishing original research manuscripts, which are rigorously selected according to their quality, originality, and interest, and also in continued medical education-oriented manuscripts, which are commissioned by the journal to relevant authors (Editorials, Reviews, and Diagnosis and Treatment). These manuscripts contain updated topics with a major clinical or conceptual relevance in modern medicine. The journal adheres to the standards of academic research publications in all aspects including peer-review and ethical principles. Medicina Clínica is included in the General and Internal Medicine category of Thomson Reuters.

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2.6

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