Mood disorder as a manifestation of primary hypoparathyroidism: a case report

Abstract

IntroductionPrimary hypoparathyroidism is a rare condition caused by parathyroid hormone deficiency and characterized by hypocalcemia. The clinical manifestations of primary hypoparathyroidism include tetany, seizures, paresthesias, dementia, and parkinsonism. Psychiatric manifestations such as mood disorders are unusual and may constitute a major diagnostic challenge, especially if the typical manifestations caused by hypocalcemia are absent.Case presentationThe patient was a 22-year-old Caucasian man with a history of chronic omeprazole use and periodic seizures, who presented to the emergency department of a secondary hospital in Southern Brazil with symptoms of major depression (sadness, anhedonia, loss of appetite, insomnia, and fatigue) associated with paresthesias affecting his toes. The initial electrocardiogram revealed a prolonged QTc interval. A computed tomography scan of his brain revealed bilateral, nonenhancing hyperdense calcifications involving the putamen and caudate nucleus. An electroencephalogram showed generalized bursts of slow spikes. Blood laboratory study results indicated serum hypocalcemia, hypomagnesemia, and hyperphosphatemia associated with a low parathyroid hormone level. His serum levels of albumin, 25-hydroxyvitamin D, thyroid-stimulating hormone, T3 and T4 thyroid hormones, as well as the results of kidney function tests, were normal. The definitive diagnosis was primary hypoparathyroidism with psychiatric manifestations due to chronic hypomagnesemia induced by proton pump inhibitor use.ConclusionsIn some cases, to differentiate between a primary psychiatric disorder and primary hypoparathyroidism with neuropsychiatric symptoms may represent a challenge given that the classical manifestations of hypocalcemia, especially tetany, may be absent in the setting of chronic hypoparathyroidism. Clinicians and psychiatrists should consider primary hypoparathyroidism part of the differential diagnosis during the evaluation of patients with mood symptoms, especially in the context of atypical presentations associated with hypocalcemia.

Psychiatric Manifestations of Endocrine Disorders

“…In a study of 62 hypoparathyroid patients, Aggarwal et al, [83] found that neuropsychological dysfunctions were present in one-third of their patients, and these dysfunctions correlated with duration of illness, female gender, serum calcium, and calcium-phosphorus product during follow-up but not with intracranial calcification. Also, Bohrer et al, [84] and Rosa et al, [85] both supported the claim that depression is associated with hypoparathyroidism and that psychiatric disorders seemed predominant in the setting of long-term hypoparathyroidism. As Bohrer et al, [84] mentioned concerning the potential proposed mechanisms of depression with hypoparathyroidism, "The exact cause of depression in cases of hypoparathyroidism is not known. "…”

“…As Bohrer et al, [84] mentioned concerning the potential proposed mechanisms of depression with hypoparathyroidism, "The exact cause of depression in cases of hypoparathyroidism is not known. " Furthermore, it was found that psychiatric symptoms did not improve with conventional antidepressants and antipsychotics until the serum calcium levels were corrected [34,85]. …”

Evidence-based and unlicensed indications for proton pump inhibitors and patients’ preferences for discontinuation: a pilot study in a sample of Italian community pharmacies

“…Proton pump inhibitors (PPIs) are among the most commonly prescribed medicines, and their overuse is widespread in both primary and secondary care, with great implications for drug costs in the industrialized world 1 . Although generally well tolerated, PPIs can cause serious adverse reactions, such as communityacquired pneumonia, Clostridium difficile diarrhoea 2 , hip fractures 3,4 , and severe hypomagnesaemia [5][6][7] with acute neurological manifestations 8,9 , and have been reported to increase all-cause mortality 10 . PPIs are effective in the treatment or prevention of peptic acid disorders, but some studies suggest that between 25% and 81% of patients taking them had no appropriate indication and in many cases physicians failed to provide specific instructions about how long to continue treatment 1,11,12 .…”

In reply: Postsurgical hypoparathyroidism is not primary hypoparathyroidism (March 2018)

“…Apical aneurysm is currently considered an independent risk factor for sudden cardiac death in HCM, with an increased rate of sudden death of up to 5% every year. 3,4 It is imperative to distinguish midventricular obstruction with LVAA as a unique disease imposing a higher risk of thromboembolism, ventricular arrhythmia, and progression to end-stage heart failure. 3 We suggest that those patients be evaluated early in the course of disease for anticoagulation, ICD implantation, and early surgical intervention.…”