骨饥饿综合征导致低钙抽搐一例报道并文献复习
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摘要
目的通过对重症监护室收治的1例骨饥饿综合征(HBS)导致低钙抽搐患者的临床特点的描述,结合系统文献回顾,总结HBS的救治要点,提高HBS的诊治水平及对其严重并发症的认识。方法回顾分析2018-01-23四川省医学科学院·四川省人民医院收治的1例HBS导致低钙抽搐患者的救治过程。在万方数据知识服务平台、中国知网、PubMed数据库中检索关于HBS导致低钙抽搐的文献,对HBS的病因及诊疗加以系统总结。结果患者为原发性甲状旁腺功能亢进,行甲状旁腺切除术后发生HBS,术后病理诊断为甲状旁腺腺瘤,术后1个月院外未正规治疗,再次入院时血钙严重低下,出现HBS导致低钙抽搐,窦性心动过速,血氧饱和度下降,经静脉推钙及大剂量持续泵入葡萄糖酸钙等抢救治疗好转。共检索到30篇关于HBS的文献,国内4篇,国外26篇,共122例患者,其中发生低钙抽搐者共4例,3例为手足抽搐,1例为舌肌抽搐导致失语;发生喉头痉挛1例;心律失常2例。HBS可分为原发性、继发性、三发性三类,原发性HBS最常见于甲状旁腺腺瘤切除术后,继发性HBS最常见于肾衰竭。原发性HBS患者平均年龄小于继发性HBS患者,且平均病程短于继发性HBS患者(P<0.001),考虑与导致HBS的病因有关。结论HBS导致严重低钙有很高的死亡风险,临床医生必须及时甄别。患病时间长,术前血清钙及血清碱性磷酸酶升高,骨骼受累严重,术前PTH水平高的原发性或继发性甲状旁腺功能亢进患者,术后易发生严重HBS导致死亡,早期术前预防评估及术后诊断非常重要,可以改善患者预后。
Objective To summarize the essentials for the rescue and treatment of hungry bone syndrome(HBS) on the basis of the clinical profile of a case of hypocalcaemic tetany caused by HBS treated by us with ICU care and the review of the related studies,in order to improve clinicians' ability to diagnose and treat HBS and their awareness of its serious complications.Methods We retrospectively analyzed the rescue and treatment process of a case of hypocalcaemic tetany caused by HBS,who admitted to Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital in 23 January,2018. Then,we reviewed the related studies searched from the electronic databases of Wanfang Data Knowledge Service Platform,CNKI,and PubMed. On the basis of the above work,we systematically summarized the causes,diagnosis and treatment of HBS. Results Our case is a 28-year-old male with primary hyperparathyroidism. He had HBS following parathyroidectomy. The postoperative pathological diagnosis was parathyroid adenoma. He did not receive any regular out-of-hospital care in 30 days after being discharged from out hospital. He was readmitted due to severe hypocalcemia,hypocalcaemic tetany caused by HBS,nodal tachycardia,and decreased blood oxygen desaturation,but was relieved after receiving intravenous injection of 10% calcium gluconate and high-dose continuous infusion of 10% calcium gluconate with the infusion pump. A total of 30 articles about HBS were retrieved,4 of them were published in China,and 26 in foreign countries. A total of 122 patients were analyzed,including 4 cases of hypocalcaemic tetany(3 cases of convulsions in hand and foot and 1 case of aphasia due to tongue twitch),1 case of laryngospasm,2 cases of arrhythmia. HBS can be classified into primary,secondary and tertiary HBS. Primary HBS often occurs after parathyroid adenoma resection,and secondary HBS mostly caused by renal failure. Compared with secondary HBS patients,primary HBS patients have a younger average age,and a shorter average duration of HBS(P<0.001),which may be caused by different causes of HBS. Conclusion As severe hypocalcemia caused by HBS has a high risk of death,clinicians should diagnose it in time. Primary or secondary hyperparathyroidism patients with a long duration of HBS,elevated levels of preoperative serum calcium,alkaline phosphatase,and parathyroid hormone,and severe bone involvement,are prone to postoperative severe HBS,which can lead to death. So preoperative evaluation and postoperative diagnosis are very important,which are conducive to the improvement of prognosis of the patients.
Objective To summarize the essentials for the rescue and treatment of hungry bone syndrome(HBS) on the basis of the clinical profile of a case of hypocalcaemic tetany caused by HBS treated by us with ICU care and the review of the related studies,in order to improve clinicians' ability to diagnose and treat HBS and their awareness of its serious complications.Methods We retrospectively analyzed the rescue and treatment process of a case of hypocalcaemic tetany caused by HBS,who admitted to Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital in 23 January,2018. Then,we reviewed the related studies searched from the electronic databases of Wanfang Data Knowledge Service Platform,CNKI,and PubMed. On the basis of the above work,we systematically summarized the causes,diagnosis and treatment of HBS. Results Our case is a 28-year-old male with primary hyperparathyroidism. He had HBS following parathyroidectomy. The postoperative pathological diagnosis was parathyroid adenoma. He did not receive any regular out-of-hospital care in 30 days after being discharged from out hospital. He was readmitted due to severe hypocalcemia,hypocalcaemic tetany caused by HBS,nodal tachycardia,and decreased blood oxygen desaturation,but was relieved after receiving intravenous injection of 10% calcium gluconate and high-dose continuous infusion of 10% calcium gluconate with the infusion pump. A total of 30 articles about HBS were retrieved,4 of them were published in China,and 26 in foreign countries. A total of 122 patients were analyzed,including 4 cases of hypocalcaemic tetany(3 cases of convulsions in hand and foot and 1 case of aphasia due to tongue twitch),1 case of laryngospasm,2 cases of arrhythmia. HBS can be classified into primary,secondary and tertiary HBS. Primary HBS often occurs after parathyroid adenoma resection,and secondary HBS mostly caused by renal failure. Compared with secondary HBS patients,primary HBS patients have a younger average age,and a shorter average duration of HBS(P<0.001),which may be caused by different causes of HBS. Conclusion As severe hypocalcemia caused by HBS has a high risk of death,clinicians should diagnose it in time. Primary or secondary hyperparathyroidism patients with a long duration of HBS,elevated levels of preoperative serum calcium,alkaline phosphatase,and parathyroid hormone,and severe bone involvement,are prone to postoperative severe HBS,which can lead to death. So preoperative evaluation and postoperative diagnosis are very important,which are conducive to the improvement of prognosis of the patients.
引文
[1]刘凯,闵翔,严丹青.腹膜透析继发甲状旁腺功能亢进术后低钙危象1例[J].临床耳鼻咽喉头颈外科杂志,2017,31(5):395-397.DOI:10.13201/j.issn.1001-1781.2017.05.017.
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[3]KAZAMA J J,SUZUKI K,YOKOSEKI A,et al.Development of hungry bone syndrome after rapid lowering of PTH with intravenous maxacalcitol therapy in a patient with non-uremic secondary hyperparathyroidism[J].Clin Nephrol,2003,60(5):369-371.DOI:10.5414/cnp60369.
[4]CAMPUSANO C,LOPEZ J M.Complete recovery of hungry bone syndrome using intravenous calcium infusion.Report of one case[J].Rev Med Chil,2003,131(7):779-784.DOI:10.4067/s30034-98872003000700010.
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[6]HARDOFF R,FRAJEWICKI V.Bone scintigraphy in hungry bone syndrome following parathyroidectomy[J].J Nucl Med,1996,37(8):1371-1373.
[7]WITTEVEEN J E,VAN THIEL S,ROMIJN J A,et al.Hungry bone syndrome:still a challenge in the post-operative management of primary hyperparathyroidism:a systematic review of the literature[J].Eur J Endocrinol,2013,168(3):R45-53.DOI:10.1530/EJE-12-0528.2013.05.
[8]KADERLI R M,RISS P,DUNKLER D,et al.The impact of vitamin D status on hungry bone syndrome after surgery for primary hyperparathyroidism[J].Eur J Endocrinol,2018,178(1):1-9.DOI:10.1530/eje-17-0416.
[9]DAVENPORT A,STEARNS M P.Administration of pamidronate helps prevent immediate postparathyroidectomy hungry bone syndrome[J].Nephrology(Carlton),2007,12(4):386-390.DOI:10.1111/j.1440-1797.2007.00806.x.
[10]FARESE S.The hungry bone syndrome-an update[J].Ther Umsch,2007,64(5):277-280.DOI:10.1024/0040-5930.64.5.277.
[11]ANDRYSIAK-MAMOS E,ZOCHOWSKA E,KAZMIERCAYK-PUCHALSKA A,et al.Treatment of severe life threatening hypocalcemia with recombinant human teriparatide in patients with postoperative hypoparathyroidism-a case series[J].Endokrynol Pol,2016,67(4):403-412.DOI:10.5603/EP.a2016.0051.
[2]胡咏新,陈国芳,刘洲君,等.原发性甲状旁腺机能亢进症术后骨饥饿综合征一例[J].江苏医药,2015,41(3):358-360.DOI:10.19460/j.cnki.0253-3685.2015.03.050.
[3]KAZAMA J J,SUZUKI K,YOKOSEKI A,et al.Development of hungry bone syndrome after rapid lowering of PTH with intravenous maxacalcitol therapy in a patient with non-uremic secondary hyperparathyroidism[J].Clin Nephrol,2003,60(5):369-371.DOI:10.5414/cnp60369.
[4]CAMPUSANO C,LOPEZ J M.Complete recovery of hungry bone syndrome using intravenous calcium infusion.Report of one case[J].Rev Med Chil,2003,131(7):779-784.DOI:10.4067/s30034-98872003000700010.
[5]AJMI S,SFAR R,TRIMECHE S,et al.Scintigraphic findings in hungry bone syndrome following parathyroidectomy[J].Rev Esp Med Nucl,2010,29(2):81-83.DOI:10.1016/j.remn.2009.10.003.
[6]HARDOFF R,FRAJEWICKI V.Bone scintigraphy in hungry bone syndrome following parathyroidectomy[J].J Nucl Med,1996,37(8):1371-1373.
[7]WITTEVEEN J E,VAN THIEL S,ROMIJN J A,et al.Hungry bone syndrome:still a challenge in the post-operative management of primary hyperparathyroidism:a systematic review of the literature[J].Eur J Endocrinol,2013,168(3):R45-53.DOI:10.1530/EJE-12-0528.2013.05.
[8]KADERLI R M,RISS P,DUNKLER D,et al.The impact of vitamin D status on hungry bone syndrome after surgery for primary hyperparathyroidism[J].Eur J Endocrinol,2018,178(1):1-9.DOI:10.1530/eje-17-0416.
[9]DAVENPORT A,STEARNS M P.Administration of pamidronate helps prevent immediate postparathyroidectomy hungry bone syndrome[J].Nephrology(Carlton),2007,12(4):386-390.DOI:10.1111/j.1440-1797.2007.00806.x.
[10]FARESE S.The hungry bone syndrome-an update[J].Ther Umsch,2007,64(5):277-280.DOI:10.1024/0040-5930.64.5.277.
[11]ANDRYSIAK-MAMOS E,ZOCHOWSKA E,KAZMIERCAYK-PUCHALSKA A,et al.Treatment of severe life threatening hypocalcemia with recombinant human teriparatide in patients with postoperative hypoparathyroidism-a case series[J].Endokrynol Pol,2016,67(4):403-412.DOI:10.5603/EP.a2016.0051.