the Department of Pediatrics, Kasturba Medical College,
Mangalore, Karnataka 575 001, India.
to: Sajitha S, Department of Pediatrics, University Medical
Center, Dr. B.R. Ambedkar Circle, Mangalore, Karnataka 575
001, India. E-mail:
received: February 12, 2002;
completed: April 22, 2002;
Revision accepted: September
A 7-day-old male
baby was referred with history of persistent multifocal
convulsions from second day of life. He was found to have
hypocalcemia, hyperphosphatemia, normal serum magnesium and normal
renal function tests. Serum parathormone was found to be elevated.
Baby was diagnosed as case of pseudohypoparathyroidism and was
treated with calcium supplementation and calcitriol. At 9 months
he was asymptomatic on treatment, with normal serum calcium and
Hypocalcemia, Serum parathormone.
(PHP) is a term used to describe several related disorders
characterised by end organ unresponsiveness to parathormone, due
to receptor or post receptor defects. The characteristic
biochemical derangements include hypocalcemia, hyperphosphatemia
and high serum parathormone levels. A Medline search did not
reveal any case report of PHP presenting as early onset neonatal
hypocalcemia. We report a case of pseudohypoparathyroidism that
presented in early neonatal period with hypocalcemic convulsions.
A 7-day-old male
baby was referred to our neonatal unit, with history of multifocal
clonic convulsions from 2nd day of life. He was the first baby of
non-consanguineous parents. Parents were healthy with normal
stature. Antenatal period was uneventful. Baby was born by vacuum
extraction weighing 3.5 kg with Apgar score of 8 at 1’ and 10 at
5’. He was breastfed within one hour of delivery. Investigations
in a local hospital revealed hypocalcemia for which calcium
supplementation and intravenous phenobarbitone were given. As
seizures persisted with 15-20 attacks per day, the baby was
referred to our hospital.
On admission, the
baby was irritable. Anterior fontanel was at level. Capillary
filling time was more than 2 seconds. There were no dysmorphic
features or skeletal malformations. Kidneys were not palpable.
Urine output was 1mL/kg/h. The rest of the systemic examination
revealed normal blood glucose and low serum calcium 5.5 mg/dL.
Septic screen including CSF analysis was negative. Blood urea was
40 mg/dL and serum creatinine was 1.2 mg%. Total protein and serum
albumin was within normal limits. As seizures persisted, screening
for metabolic disorders was done. Urine for metabolic screen was
negative and serum ammonia was normal. ABG analysis showed normal
pH and bicarbonate. Baby was started on calcium gluconate 75
mg/kg/day and intravenous phenobarbitone and phenytoin. The
seizures persisted, and calcium remained low (6.2 mg/dL). Further
investigations revealed serum phosphorous of 7.9 mg/dL (normal:
3.8 – 6.5 mg/dL) and alkaline phosphatase of 1053 IU/L (normal:
145-420 IU/L). Serum magnesium was 1.8 mg/dL (normal: 1.5-2.5 mg/dL).
Ultrasound of abdomen did not reveal any abnormality. Blood urea
and S. creatinine when repeated on fourth day of admission were 24
mg/dL and 0.6 mg/dL respectively. DTPA renal isotope scan showed
normal renal function. The serum parathormone level by
radioimmunoassay was 92 pg/mL (normal: 12-72 pg/mL), when serum
calcium was 6.8 mg%. CT scan head was normal with no evidence of
intracranial calcification. X-ray wrist did not reveal any
shortening of metacarpals. Serum calcium, phosphorus and alkaline
phosphatase of the mother were normal.
With evidence of
persistent hypocalcemia, hyperphosphatemia, normal renal function
and high serum parathormone levels, a diagnosis of PHP was made.
The baby was treated with calcium supplementation and calcitriol
0.25 µg/day. Anticonvulsants were changed to carbamazepine.
Within 1 week of starting calcitriol, serum calcium and phosphorus
became normal. On follow up at 9 months, the baby was asymptomatic
on calcitriol (0.25 µg/day) and calcium supplementation. Urine
calcium to creatinine ratio was maintained within normal limits.
is divided into 2 main types. Type I is characterised by low or
absent renal CAMP production in response to parathormone (PTH).
Type II responds to PTH with normal increase in urinary CAMP but
show absent or subnormal phosphaturic response(1). Type I is
further subdivided into 2 subtypes A and B. In type A that
accounts for 60% of type I, the defect is localised to a subunit
of GS protein(2). Most of these patients have distinctive
morphological abnormalities collectively called "Albrights
herediatry osteodystrophy". In this type hypocalcemia rarely
develop before 3 years(3,4). In reported cases the age of onset of
type II ranged from 1.8 - 70 yrs(3).
In the case
described above, the baby presented in the early neonatal period
with hypocalcemic convulsions. Predisposing factors of early onset
hypocalcemia like prematurity, maternal diabetes or
hyperparathyroidism, birth asphyxia etc were excluded. There was
no evidence of hypomagnesemia or septicemia in the baby. Renal
failure was excluded by normal renal isotope scan and renal
function tests. Hypoparathyroidism (HP), which is more common in
neonatal period, can also produce hypocalcemia and
hyperphosphatemia. Serum parathormone levels are low or
undetectable in HP while in PHP; the levels are elevated due to
PTH resistance. There are few reports in neonates of transient PHP
that presented as late onset hypocalcemia(5-6). In these patients
PHP state was transient and resolved by 6 months of age. We tried
weaning the child of calcitriol and calcium supplementation at 6
months, but restarted it as the baby developed hypocalcemia and
hyperphosphatemia. At 9 months of age, on follow up, the present
baby required calcitriol (0.25 µg/day 12 hrly) and calcium
supplementation to maintain normal S. calcium and phosphorus. This
baby needs further follow up to understand the course of the
The main goal of
therapy in these patients is to restore serum calcium and
phosphorus as close to normal as possible. Replacement therapy
with calcitrol combined with calcium supplementation and
phosphorus restriction usually suffices to regulate blood calcium
and phosphorus levels. These patients require regular monitoring
of serum calcium, phosphorus, renal function tests and urinary
calcium excretion by urinary calcium to creatinine ratio.
PNK, UVS and SS were involved in the management of the patient and
drafting of the manuscript. SS will act as the guarantor for the
1. Vasicek T.J.
Mc Devitt Be, Freeman MW, Fennick BJ, Hendy GH, Potts J et al.
Nucleotide sequence of human PTH gene. Proc Natl Acad Sci USA
1983; 80: 2127-2131.
2. DiGeorge AM.
Pseudohypothyroidism. In: Nelson Textbook of Pediatrics,
16th edn. Eds. Behrman Er, Kliegmann RM, Arvin AM. Philadelphia,
W.B. Saunders Co. 2000: pp 1718-1719.
3. Drezner MK,
Neelson FA. Pseudohy-poparathyroidism. In: The metabolic
basis of inherited disease. Eds. Stanbury JB, Wyngaarden JB,
Friderickson DS. New York, Mc Graw-Hill, 1983; pp 1508-1527.
4. Monn E, Osnes
JB, Wefring KW. Pseudohypoparathyroidism - a difficult diagnosis
in early childhood. Acta Pediatr Scand 1976; 65: 487-493.
5. Manzar S.
Transient pseudohypoparathy-roidism and neonatal seizure. J Trop
Pediatr 2001, 47: 113-114.
6. Minagawa M, Yasuda T,
Kobayashi Y, Niimi H. Transient pseudohypoparathyroidism in
neonate. Eur J Endocrinol 1995; 133: 151-155.