23-year-old female presented to the Emergency Room with carpopedal spasms and tingling numbness in hands. Patient endorsed tingling sensation in hand since a month which was intermittent and unrelated to wrist movement. She denied history of preceding trauma and swelling in hands. There was no history of similar complaints in the past or any prior surgery. She denied complaints like nausea, vomiting, and diarrhea. Tingling in hands was not associated with paresthesia in other extremities and sensory or motor deficits. Patient was a known case of multidrug resistant tuberculosis and was being treated with the following drugs for two months: amoxicillin-clavulanate, ethionamide, intramuscular capreomycin, linezolid, and para-aminosalicylate (PAS) granules. Patient was afebrile and her initial vital signs were normal with a pulse of 78/min and blood pressure of 110/76 mm of Hg. On examination, flattening of chest wall on the left side was noted. Trail's sign was positive with a deviation of the trachea to the left side. On auscultation of lung fields, breath sounds were diminished on the left. These findings suggested presence of tuberculous fibrosis in the left lung. No other stigmata of TB were noted and rest of the physical examination was unremarkable.
Initial blood-work at the time of presentation revealed a low serum calcium level of 6.98 mg/dL. Patient was hospitalized and detailed investigations were done. Coexisting with hypocalcemia, other electrolyte abnormalities noted were as follows: serum sodium of 130 mEq/L, potassium of 1.8 mEq/L, chloride of 95 mEq/L, calcium of 6.98 mg/dL, and magnesium of 0.5 mg/dL. Serum albumin was 4 g/dL. Serum creatinine was normal and remained so throughout the course of hospitalization. The arterial blood gas evaluation showed metabolic alkalosis without respiratory compensation with pH of 7.5, HCO3 of 30 mEq/L, and PaCO2 of 30 mmHg. Routine urine examination revealed a 2-4 pus cells, 1-2 RBCs, and 1-2 epithelial cells, in the absence of proteinuria and glycosuria. Urine calcium/creatinine ratio was 0.49 (>0.2), which confirmed hypercalciuria. Urinary prostaglandin-E level was not performed as this assay is not readily available in our institute.
Vitamin D and serum parathyroid levels were found to be in the normal range, thus ruling out hypovitaminosis D and secondary hyperparathyroidism, respectively. Patient was treated symptomatically; injectable calcium, magnesium, and potassium were administered to correct electrolyte abnormalities. Due to the association of aminoglycoside antibiotics with alterations in electrolyte levels, capreomycin was discontinued. Subsequently, the electrolytes started to rise after two days of stopping capreomycin (Table 1). Patient was discharged once her symptoms resolved and the serum electrolytes were normalized. On follow-up, there were no complains of tingling sensations or carpopedal spasms and electrolytes remained to be in the normal range.