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• Other mechanisms for coeliac disease-related hypocalcaemia
  oscar,m jolobe
  Published on: 21 October 2021

• Published on: 21 October 2021

  Other mechanisms for coeliac disease-related hypocalcaemia

  • oscar,m jolobe, retired geriatrician manchester medical society

  For the sake of completeness, the account of underlying causes of hypocalcaemia(Table 2)(1) should also include hypoparathyroidism-related hypocalcaemia attributable to magnesium deficiency(2), and coeliac disease-related hypocalcaemia which is not attributable to vitamin D deficiency(3). The role of hypoparathyroidism was documented in a 12 year old patient in whom hypoparathyroidism was thought to be attributable to inhibition of parathyroid hormone(PTH) release as a result of coeliac disease(CD)-related magnesium malabsorption. This patient had been admitted with hypocalcaemia, hypomagnesemia, hyperphosphataemia and subnormal serum vitamin D level of 8 mg/ml(normal 20-45 ng/ml). The plasma parathyroid hormone(PTH) level(14.6 pg/ml; normal > 12 pg/ml) was only minimally elevated, which was inappropriate in relation to the plasma calcium level of 5.1 mg/dl. Sm,all bowel biopsy showed moderate villous atrophy. Despite treatment with gluten free diet(GFD), and replacement therapy comprising vitamin D, calcium, magnesium , and aluminium hydroxide as a phosphate binder, calcium and magnesium levels were initially persistently low and phosphorus levels were persistently high. Furthermore, serum PTH levels also subsequently became undetectable. It was only after magnesium levels and calcium levels rose that phosphorus levels and serum PTH levels normalised. The authors hypothesised that CD had been the underlying cause of both the hypocalcaemia and...

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  For the sake of completeness, the account of underlying causes of hypocalcaemia(Table 2)(1) should also include hypoparathyroidism-related hypocalcaemia attributable to magnesium deficiency(2), and coeliac disease-related hypocalcaemia which is not attributable to vitamin D deficiency(3). The role of hypoparathyroidism was documented in a 12 year old patient in whom hypoparathyroidism was thought to be attributable to inhibition of parathyroid hormone(PTH) release as a result of coeliac disease(CD)-related magnesium malabsorption. This patient had been admitted with hypocalcaemia, hypomagnesemia, hyperphosphataemia and subnormal serum vitamin D level of 8 mg/ml(normal 20-45 ng/ml). The plasma parathyroid hormone(PTH) level(14.6 pg/ml; normal > 12 pg/ml) was only minimally elevated, which was inappropriate in relation to the plasma calcium level of 5.1 mg/dl. Sm,all bowel biopsy showed moderate villous atrophy. Despite treatment with gluten free diet(GFD), and replacement therapy comprising vitamin D, calcium, magnesium , and aluminium hydroxide as a phosphate binder, calcium and magnesium levels were initially persistently low and phosphorus levels were persistently high. Furthermore, serum PTH levels also subsequently became undetectable. It was only after magnesium levels and calcium levels rose that phosphorus levels and serum PTH levels normalised. The authors hypothesised that CD had been the underlying cause of both the hypocalcaemia and the hypomagnesemia. The latter , in turn, had inhibited PTH release, thereby aggravating the hypocalcaemia. Ultimately, rigorous adherence to GFD led to normalisation of serum magnesium and, hence, normalisation of serum PTH, thereby contributing to GFD-related normalisation of serum calcium levels.(2).
  In the adult context coeliac disease(CD) can also manifest as isolated hypocalcaemia in the presence of normal serum magnesium, normal serum phosphorus, normal vitamin D levels, and appropriately elevated serum PTH. This scenario was reported in a 36 year old woman in whom the clinicians hypothesised that hypocalcaemia was solely attributable to CD-related malabsorption of calcium, independent of vitamin D status(3). A similar scenario would be plausible in paediatrics , although hitherto unreported in that context.
  I have no funding and no conflict of interest.
  References
  (1) Nadar R., Shaw N
  Investigation and management of hypocalcemia
  Arch Dis Child 2020;105:399-405
  (2)Yerushalmi B., Lev-Tzion R., Loewenthal N
  Refractory hypoparathyroidism in a child with celiac disease
  IMAJ 2016;18:58-60
  (3)Rickels MR., Mandel SJ
  Celiac disease manifesting as isolated hypocalcemia
  Endocr Parct 2004;10:203-207

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  Conflict of Interest:
  None declared.

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