MON-464 A Rare Case of Hypocalcemia-Induced Intractable Vomiting Requiring PEG Tube Placement

Introduction: Hypoparathyroidism is characterized by hypocalcemia and hyperphosphatemia secondary to inadequate PTH secretion. Clinical manifestations are carpopedal spasm, perioral paresthesia, and seizures. Herein, we present a case of hypoparathyroid-induced hypocalcemia requiring PEG tube placement. Case Presentation: Patient is a 41-year-old female who presents with intractable nausea, continuous vomiting, abdominal pain, and perioral paresthesia for the past 4 days. Patient has a past medical history significant for hypoparathyroidism, severe hypocalcemia, hypomagnesemia, hyperphosphatemia, and iron deficiency anemia. Patient was diagnosed with hypoparathyroidism at the age of 16 when her son was born with congenital abnormalities due to severe maternal hypocalcemia. She has 4 children, 1 son passed away in infancy from severe hypocalcemia. Out of the remaining 3 children, 2 daughters have hypoparathyroidism. Patient has had multiple recurrent admissions for severe hypocalcemia presenting as angina, syncope, and left-sided weakness. Both cardiology work up and neurology workup have been negative. MRI of the brain shows basal ganglia calcifications. Labs are significant for corrected calcium 6.72 mg/dL (n 8 to 10 mg/dL), magnesium 1.4 mg/dL (n 1.7 to 2.2 mg/dL), phosphorus 7.4 mg/dL (n 2.4 to 4.5 mg/dL), Vitamin D 14.9 ng/mL (n 30 to 100 ng/mL), and PTH level 9.8 pg/mL (n 18.5 to 88 pg/mL). Prior ACTH stimulation test was within normal limits excluding adrenal insufficiency. EGD biopsy on prior admission was positive for H. Pylori, however patient left against medical advice and did not receive triple therapy. Patient was admitted for hypocalcemic crisis and placed on a calcium gluconate drip, oral calcium, magnesium, calcitriol, and Vitamin D, in addition to H. pylori triple therapy. During the hospitalization, she was unable to tolerate oral medications for greater than 2 weeks resulting in PEG placement. The patient’s electrolytes were successfully repleted via PEG tube and she was discharged. Discussion: Spontaneous hypoparathyroidism is a rare metabolic disorder characterized by parathyroid glands that do not produce or secrete enough PTH to maintain normal levels of calcium and phosphorous in the blood. Though GI consequences such as steatorrhea may occur, to our knowledge, this is the first reported case of hypocalcemia-induced intractable vomiting requiring PEG tube. Before PEG placement, the patient had 12 admissions in 1 year. After PEG placement, the number dropped significantly to 4 admissions in 1 year. Due to the unique presentation of hypoparathyroid hypocalcemia, we would like to raise awareness regarding such a presentation which can be challenging for clinicians. References: Abboud B, Daher R, Boujaoude J. Digestive manifestations of parathyroid disorders. World J Gastroenterol. 2011;17(36):4063-4066. doi:10.3748/wjg.v17.i36.4063.