A 10Year Old Boy with Pain Induced Seizures

Lorin M. Henrich, Alan D. Rogol, and David E. Bruns

A 10-year-old male with a history of learning disabilities, developmental delay, and attention deficit hyperactivity disorder (ADHD) suffered a nonfebrile seizure after he hit his knee while getting into the shower. The patient had no prior history of seizure, but his mother had experienced multiple "pain-induced" seizures. The patient was in no apparent distress and his respiration, pulse, and blood pressure were normal. He denied headaches or visual problems and had no evidence of a head injury. An EEG and head CT were normal. STAT serum chemistry tests revealed hypercalcemia (Table 31.1). The following values were found:

Concentration,

Reference Interval,

Reference

Conventional

Conventional

Concentration,

Interval,

Analyte

Units

Units

SI Units

SI Units

Sodium

138 mmol/L

137-145

Same

Potassium

4.6 mmol/L

3.6-5.0

Same

Chloride

104 mmol/L

98-107

Same

CO2

23 mmol/L

18-27

Same

Glucose

87 mg/dL

65-110

4.8 mmol/L

3.6-6.1

Total calcium

12.0 mg/dL

8.5-10.5

3.1 mmol/L

2.2-2.7

Phosphorus

3.1 mg/dL

4.0-7.0

1.0 mmol/L

1.3-2.3

Creatinine

0.6 mg/dL

0.7-1.3

53 mol/L

62-115

On evaluation by a pediatric endocrinologist, the patient denied symptoms of hypercalcemia, including abdominal pain, constipation, muscle pain, or tiredness. A soft right parasternal murmur was noted. The finding of hypercalcemia in combination with arrhythmia was suggestive of Williams syndrome, but an EKG was normal and echocardiogra-phy revealed no evidence of supravalvular aortic stenosis or any cardiac abnormality. Additional laboratory studies were obtained:

Value,

Reference Range,

Conventional

Conventional

Value,

Reference Range,

Analyte

Units

Units

SI Units

SI Units

Albumin

4.7 g/dL

3.5-5.0

47 g/L

35-50

Total calcium

12.2 mg/dL

8.5-10.5

3.2 mmol/L

2.2-2.7

Ionized calcium

7.0 mg/dL

4.5-5.6

1.7 mmol/L

1.1-1.4

Phosphorus

3.1 mg/dL

4.0-7.0

1.0 mmol/L

1.3-2.3

Creatinine

0.9 mg/dL

0.7-1.3

80 mol/L

62-115

Magnesium

2.4 mg/dL

1.6-2.3

1 mmol/L

0.66-0.95

Anion gap

14 mmol/L

12 - 20

Same

ALP

215 U/L

50-380

Same

Intact PTH

60.3 pg/mL

10.0-65.0

6.6 pmol/L

1.1-7.1

T4

6.3 mg/dL

5-12

81 nmol/L

64-154

TSH

1.73 mU/mL

0.7-7.0

1.73 mU/L

0.7-7.0

Urine calcium

237 mg/24 hours

42-353

5.9 mmol/day

1.0-8.8

Urine phosphorus

842 mg/24 hours

400-1300

27 mmol/day

13-42

Urine creatinine

903 mg/24 hours

600-2500

8 mmol/day

5-22

Total urine volume

1220 mL

The patient's hypercalcemia was accompanied by hypophosphatemia and normo-calciuria. The thyroid function tests did not suggest hyperthyroidism, and the anion gap showed no evidence of metabolic acidosis. Plasma PTH was within the reference interval, but inappropriately high for the calcium concentration. On the basis of these results, a diagnosis of mild primary hyperparathyroidism was reached. Because the patient's mother had a history of seizures, familial hypocalciuric hyperparathyroidism (FHH) was included in the differential. Both parents were evaluated for hypercalcemia and hypo-phosphatemia, and were found to be normal. A 99m-technetium sestamibi scan of the patient's parathyroid region demonstrated no evidence of adenoma or ectopic tissue. Because the patient was asymptomatic, no immediate action was taken.

Over the next few years, the patient's calcium remained between 11.0 and 12.2 mg/dL. His plasma PTH was stable, and he remained asymptomatic. Five years after the initial diagnosis, the patient developed dysuria and symptoms consistent with nephrolithiasis, and he thus underwent parathyroidectomy. Immediately before removal of any glands, the plasma PTH was 260pg/mL. Three and one-half enlarged-appearing glands were then removed. Intraoperative PTH values of 50 pg/mL and 56 pg/mL were obtained at 25 and 45 minutes after gland removal. The observed decline in PTH indicated that the bulk of the hyperfunctioning tissue had been removed, and the surgery was completed. Histologic evaluation of the resected parathyroid tissue indicated diffuse hyperplasia of all four glands.

Understanding And Treating ADHD

Understanding And Treating ADHD

Attention Deficit Disorder or ADD is a very complicated, and time and again misinterpreted, disorder. Its beginning is physiological, but it can have a multitude of consequences that come alongside with it. That apart, what is the differentiation between ADHD and ADD ADHD is the abbreviated form of Attention Deficit Hyperactive Disorder, its major indications being noticeable hyperactivity and impulsivity.

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