Hypoparathyroidism, an unusual stroke mimic.
Dr Sarah Duncan, Dr Jessica Longley, Professor Lionel Ginsberg.
A 75 year old woman was brought to A&E by ambulance as a stroke thrombolysis call. She was hypertensive and tachycardic with left sided facial weakness and a reduced GCS. CT head showed no acute bleed or infarct. Later she developed spontaneous twitching of the legs, this was felt to be seizure activity and phenytoin was loaded. A diagnosis of probable acute infarct was made and the patient was transferred to the Hyperacute Stroke Unit.
At 09:00 the patient was assessed on the ward round and found to have signs not fitting an acute stroke. GCS 8/15, no response to left sided visual threat; disconjugate gaze; flexing both arms to pain, positive Babinski sign bilaterally. A venous blood gas was reviewed and low ionised calcium noted 0.77mmol/L, formal laboratory result was pending.
At 10:00 the team were called to see the patient with a heart rate of 170bpm, supraventricular tachycardia (SVT) was demonstrated on ECG. 6mg bolus of adenosine was given, leading to immediate resolution of arrhythmia. Repeat urgent bloods were sent.
At 10.45 the patient had a further episode of SVT which again resolved with 6mg adenosine. Corrected calcium result from laboratory was now available, 1.6mmol/L. The patient was given 10ml 10% calcium gluconate and transferred to HDU for monitoring.
The patient made a significant recovery with no further arrhythmia's or seizure activity. The only complication to her HDU stay was considerable epistaxis following nasogastric tube insertion, this required packing for 24 hours to stop the bleeding. At this point a collateral history was obtained from her GP, confirming a history of hypoparathyroidism.
This case represents an unusual example of hypocalcaemia presenting as a stroke mimic. However in retrospect we can see that the patient demonstrated classical symptoms of hypocalcaemia: confusion, tetany, cardiac arrhythmias and increased bleeding tendancy.
The learning points from this case are include the importance of keeping an open mind when the patient presents to a specialist team with a presumed diagnosis and that electrolyte imbalance is a key differential in patients presenting with reduced level of consciousness and inconsistent neurology.