Jessica Sempler PGY3

7/30/14
7do female infant presented to the ED with
tactile fever and tonic clonic extension of her
left arm and leg x3 episodes at home
Tonic clonic episodes last 30sec-1min,
accompanied by abnormal head movement
Feeding slightly less well today







Born at 37 2/7 weeks to a 25yo G3P1102
GBS unknown
No h/o genital HSV in either parent
NSVD with clear fluids
APGARS 9/9
BW 2740g
D/C from hospital on DOL 2
Bilateral cleft lip and palate, f/u with Plastic
Surgery scheduled for the following week

T 39.4, HR 170, R 88, BP 69/38, 92% on RA, Wt 2.7Kg

GEN: Awake, alert, no acute distress
HEENT: AFOSF with no bulging, no scleral icterus, b/l
cleft lip and palate
PULM: Tachypneic, LCTAB with symmetric breath
sounds
CV: S1, S2 with no murmurs, 2+ peripheral pulses, 3sec
capillary refill
ABD: S/NT/ND, active bowel sounds, no HSM
NEURO: Appropriate tone, but with tonic clonic
activity reportedly witnessed by ED nurse and tech


FEVER:
SBI ; especially HSV
Viral illness

SEIZURE ACTIVITY:
Febrile seizure
Hypoglycemia
Electrolyte abnormality
NAT
Stroke
Infantile spasm
Metabolic disease

CT Brain

Full ROS
VRP -
WBC 10.1, 5% bands
UA with small Hgb, 2+ protein
CSF with 11 WBC, 174 RBC, Protein 94, Glucose
50
Upper limit for WBCs in CSF = 18 if >29d


CMP WNL except Ca 5.2


iCal 0.76 (1.19-1.50)
Phos 8.8 (4.8-8.2)
Mag 1.2 (1.6-2.3)

Vit D (P)
PTH (P)

Causes of Hypocalcemia
in children

HYPOPARATHYROIDISM:
Maternal
hyperparathyroidism

HYPOVITAMINOSIS D:
Low maternal Vitamin D

MISCELLANEOUS:
Sepsis/critical illness

View the chart in UpToDate article:

Etiology of hypocalcemai in
infants and children.

(Unable to publish due to copyright. )
Ampicillin
Cefotaxime
Acyclovir

Load with 10mg/Kg IV Phenobarbital

CaGluconate IV
MagSulfate IV
Ingestion of excessive phosphate from
evaporated milk or modified cow milk
formulas
Marked tissue breakdown resulting in release
of intracellular phosphate
Renal failure
Formation of poorly soluble
CaPhos salts

22q11 deletion syndrome
Conotruncal cardiac anomalies
Hypoplastic thymus
Hypocalcemia (d/t parathyroid hypoplasia)

Occurs in 1:4,000 births
Most common form of dysgenesis of
parathyroid glands in neonates and infants
Disturbed migration of cervical neural crest
cells
Renal wasting
GI losses
Magnesium depletion causes impaired
synthesis or secretion of parathyroid hormone
(Suh et al 1973)

Magnesium corrected after repletion in ED
Calcium remained low despite repeated IV
repletion
Vitamin D 16 (L)
~8 beats of clonus, jittery infant


1. Start PO Calcium supplements and Vitamin D
suppplements
Ca Carbonate
Calcitriol
Cholecalciferol

2. Await results of PTH prior to testing for
DiGeorge
Due to copyright restriction view
algorithm in UpToDate article:
Overview of vitamin D
PTH 20 (15-65); c/w hypoparathyroidism
Cleft palate alone is more common than cleft
lip with cleft palate
Genomic SNP microarray; to capture a wider
array of genomic imbalances beyond del22q11,
which would be picked up with FISH
Discharged to home on Ca supplements and
Vit D
Diagnosis of late neonatal hypocalcemia,
defined as occuring after the 2
nd
or 3
rd
day of
life, usually at the end of the first week
Plan to test Mom for hyperparathyroidism if
SNP microarray normal

Neonatal hypocalcemia http://www.uptodate.com/contents/neonatal-
hypocalcemia?source=search_result&search=neonatal+hypocalcemia&selectedTitle=1%7
E11
DiGeorge syndrome: Clinical features and diagnosis
http://www.uptodate.com/contents/digeorge-syndrome-clinical-features-and-
diagnosis?source=search_result&search=DiGeorge&selectedTitle=1%7E62
Overview of vitamin D http://www.uptodate.com/contents/overview-of-vitamin-
d?source=search_result&search=Vitamin+D&selectedTitle=2%7E150
Sanjad-Sakati syndrome in Omani children
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191633/
Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes
http://ghr.nlm.nih.gov/condition/mitochondrial-encephalomyopathy-lactic-acidosis-
and-stroke-like-episodes
Hypocalcemia in the neonate and infant https://www.inkling.com/read/sperling-
pediatric-endocrinology-4th/chapter-18/hypocalcemia
Pathogenesis of Hypocalcemia in Primary Hypomagnesemia: Normal End-Organ
Responsiveness to Parathyroid Hormone, Impaired Parathyroid Gland Function
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC302237/