Hungry bones syndrome most commonly occurs following parathyroidectomy and is attributed to the increased influx of calcium into the bone, after circulating serum parathormone has been subjected to an abrupt decrease [1] [2]. The disorder leads to profound hypocalcemia and hypophosphatemia, findings which give rise to various symptoms.

The considerable hypocalcemia causes cardiovascular and neurologic or neuromuscular symptoms. The symptoms associated with hungry bones syndrome include syncopic events, angina pectoris, and congestive heart failure [3]. Bradycardia, tachycardia, an S3 cardiac tone and signs such as dyspnea, fatigue and edemas may be observed.

As far as neurological symptoms are concerned, hungry bones syndrome may lead to irritability, profound fatigue, and exhaustion, as well as depression, psychosis, hallucinations and personality alterations. The patient may exhibit the epileptic activity of various types, such as petit or grand mal seizures and focal epilepsy, while intellectual capacity and perception may also appear abnormally decreased. Neuromuscular involvement may be observed, as the patient may develop dysphagia or laryngospasm due to contractions of the smooth muscles or wheezing sounds, that can be heard during auscultation. The patient may also report paresthetic phenomena in the extremities, as well as cramps in the feet and back, that may be further exacerbated to the point that tetany appears [4]. Intestinal and biliary colic can also occur as a result of hypocalcemia, as can hemiballism, parkinsonism, and choreoathetosis [5].

The physical examination for hypocalcemia includes the Chvostek and Trousseau signs [6]. The positive Chvostek sign is indicative of hypocalcemia and encompasses a tap on the skin above the facial nerve about 2 cm anterior to the external auditory meatus, which elicits an ipsilateral contraction of the facial muscles. However, the Chvostek sign can exist in conditions other than hypocalcemia and is, therefore, non-specific for the condition. The Trousseau sign involves a carpal spasm, induced when a blood pressure cuff is inflated to 20 mmHg for approximately 5 minutes.

• Fatigue

  Bradycardia, tachycardia, an S3 cardiac tone and signs such as dyspnea, fatigue and edemas may be observed. [symptoma.com]

  Other features include fatigue, polyuria and polydipsia, muscular asthenia, nausea, vomiting, loss of appetite and weight loss (7). [ijptm.com]

  Sestamibi scan demonstrating a parathyroid adenoma in a 54-year-old woman with an elevated calcium level discovered during an evaluation for fatigue. [aafp.org]

  […] distal clavicles  salt-and-pepper appearance of the skull  brown tumors of the long bones  chronically hypercalciuria predisposes to the formation of renal stones. 12. symptoms of hyperparathyroidism are due to the hypercalcemia  muscle weakness  fatigue [slideshare.net]

  If you do get to sleep, it’s common to wake up feeling fatigued because you’ve been moving all night, even though you didn’t wake up — but you won’t necessarily feel sleepy during the day. [womenshealthnetwork.com]

• Anemia

  The resolution of anemia after curative parathyroidectomy is sustained even after a decade. Indian J Clin Endocrinol Metab 2015; 19(5):691-2. [clinicalcases.eu]

  Parathyroidectomy and improving anemia. Arch Surg. 2008;143(1):97-8. DOI: 10.1001/archsurg. 2007.26 34. Gasparri G, Camadona M, Abbona GC, Papotti M, Jeantet A, Radice E, et al. [degruyter.com]

  P74 ) Endocrine, nutritional and metabolic diseases E70-E88 2019 ICD-10-CM Range E70-E88 Metabolic disorders Type 1 Excludes androgen insensitivity syndrome ( E34.5- ) congenital adrenal hyperplasia ( E25.0 ) Ehlers-Danlos syndrome ( Q79.6 ) hemolytic anemias [icd10data.com]

  Mucocutaneous candidiasis, alopecia, vitiligo, and pernicious anemia are associated with this disorder, which is referred to as polyglandular autoimmune disease (PGA I). [emedicine.medscape.com]

• Weight Gain

  This may happen even earlier, especially if there is a period of rapid weight gain. Children may then enter puberty, which accelerates bone age even further. [rarediseases.org]

• Stridor

  […] joint extension, and the Chvostek sign, which occurs when one taps on the facial nerve in front of the ear causing a contraction of the muscles of the eye, mouth, and nose. 4 Tetany may be associated with numbness, cramps, carpopedal spasm, laryngeal stridor [consultant360.com]

  In serious cases, stridor, bronchospasm, cardiac arrhythmias, angina, cardiac failure, syncope, and seizures may occur. Symptomatic POH seldom manifests unless TSC falls below the threshold of 2.0 mmol/L (8.0 mg/dL) [ 3 ]. [medsci.org]

• Diarrhea

  Oral magnesium supplementation is limited by diarrhea, however it can be provided as magnesium oxide 400 mg 1-2 tabs per day. [ijptm.com]

  As large oral amounts of magnesium may induce severe diarrhea and noncompliance in some patients, parenteral magnesium administration must sometimes be considered. [emedicine.medscape.com]

  To diagnosis idiopathic hypoparathyroidism, the following criteria are necessary: low serum calcium levels; high serum phosphorous levels; and the absence of renal insufficiency, steatorrhea, chronic diarrhea, and alkalosis. [consultant360.com]

• Bone Pain

  In this article, we report the case of a 48-year-old woman with bone pain and multiple brown tumors as the first manifestation of primary hyperparathyroidism due to a large parathyroid adenoma. [ncbi.nlm.nih.gov]

  Oncogenic osteomalacia is a paraneoplastic syndrome of osteomalacia, hypophosphataemia, renal phosphate loss, bone pain, and muscle weakness. [patient.info]

  Except for a cast on her left leg, musculoskeletal examination is normal and reveals no bone pain. [acphospitalist.org]

  "Stones" refers to kidney stones, "bones" to associated destructive bone changes, "groans" to the pain of stomach and peptic ulcers that occur in some cases, and "moans" to the depression that frequently accompanies the disease and is often its first [en.wikipedia.org]

• Muscle Cramp

  Severe symptoms of hypocalcemia include: confusion or memory loss muscle spasms numbness and tingling in the hands, feet, and face depression hallucinations muscle cramps weak and brittle nails easy fracturing of the bones Calcium deficiencies can affect [healthline.com]

  We observed closely for development of any symptoms of hypocalcemia such as paraesthesia, muscle cramps, twitching or carpopedal spasm. IV magnesium was also promptly replaced postoperatively. [casereports.in]

  Other manifestations include the following: Convulsions Apathy Muscle cramps Hyperreflexia Acute organic brain syndromes Depression Generalized weakness Anorexia Vomiting Magnesium is required for stabilization of the axon. [emedicine.medscape.com]

• Carpopedal Spasm

  spasm, laryngeal stridor, and generalized convulsions. [consultant360.com]

  Symptoms of severe hypercalcaemia Symptoms of severe acute hypocalcaemia Fatigue Syncope Weakness Angina Polydipsia Congestive heart failure (reversible) Polyuria Perioral and/or finger tingling and numbness Dehydration Carpopedal spasm, Chvostek sign [omicsonline.org]

  We observed closely for development of any symptoms of hypocalcemia such as paraesthesia, muscle cramps, twitching or carpopedal spasm. IV magnesium was also promptly replaced postoperatively. [casereports.in]

• Muscle Spasm

  Severe symptoms of hypocalcemia include: confusion or memory loss muscle spasms numbness and tingling in the hands, feet, and face depression hallucinations muscle cramps weak and brittle nails easy fracturing of the bones Calcium deficiencies can affect [healthline.com]

• Leg Cramp

  No other condition, either medical or behavioral, can account for any of the above considerations (meaning, your condition will be diagnosed as RLS only if you have no other conditions, such as leg cramps, arthritis, obsessive-compulsive disorder, or [womenshealthnetwork.com]

  I can be sitting with my feet up and suddenly my toes will go in to contraction and I will get really painful leg cramps, feels like my leg is going to break. [medhelp.org]

Acute hypocalcemia constitutes a medical emergency and should be promptly evaluated and corrected.

As a first step, true hypocalcemia should be distinguished from factitious hypocalcemia [7]. Serum albumin needs to be measured, in order to detect whether the patient is suffering from true hypocalcemia (decreased ionized calcium) or factitious hypocalcemia, otherwise referred to as pseudohypocalcemia, where the total calcium is decreased, but ionized calcium remains unaffected.

Parathyroid hormone (parathormone or PTH) levels also need to be evaluated; vitamin D measurement is also mandatory, should there be any suspicion towards its deficiency. Parathormone insufficiency may coexist with normal or mildly decreased serum alkaline phosphatase (ALP). Liver function tests need to be performed in order to assess the overall hepatic functionality, alongside coagulation factors, blood urea nitrogen and creatinine levels.

Electrocardiography can also be employed in order to detect a potentially prolonged QT segment [8]. A plain radiograph can also help to illustrate malignancies or benign tumors of the skeletal system, that may lead to hypocalcemia.

• Calcium Decreased

  By negative feed back, raised serum ionised calcium decreases PTH secretion to maintain adequate serum calcium levels [ 3 ]. [omicsonline.org]

Because this treatment also did not control the hypophosphatemia and hypocalcemia, treatment with oral dipyridamole was started. [sjkdt.org]

The patient required a 72-hour hospitalization and treatment with a continuous intravenous calcium infusion for symptomatic hypocalcemia. The intact parathyroid hormone level at this time was 176 pg/mL. [wwww.unboundmedicine.com]

545 Dialysis ultrafiltration and hemofiltration 555 Use of drugs in uremia and dialysis 567 Donor and recipient selection in renal transplantation 587 Immunosuppression and treatment of rejection in renal transplantation 595 XIII 606 Renal tubular and [books.google.com]

This syndrome is characterized as a state of hypocalcaemia where there are large calcium deposits to a bone, and the effects can be short lived or last years depending on treatment. [healthguideinfo.com]

Diagnosis is more problematic in non-functional lesions and the prognosis is worse due to delay in diagnosis. [ijptm.com]

Prognosis Correction of acute hypophosphataemia tends to leave no long-term complications but failure to recognise and treat an acute, severe situation can lead to fatality. [patient.info]

Prognosis Hypomagnesemia has been linked to poor outcome in several different patient populations. [emedicine.medscape.com]

Hypoparathyroidism may also have a variety of other etiologies. Injury to or removal of the parathyroid glands during neck surgery is the most common cause of hypoparathyroidism. [consultant360.com]

Parathyroid carcinoma: etiology, diagnosis, and treatment. World J Surg. 2009 Nov;33(11):2343–54. Kebebew E, Arici C, Duh QY, Clark OH. Localization and reoperation results for persistent and recurrent parathyroid carcinoma. [ijptm.com]

(See Etiology, Presentation, and Workup .) Almost all enzymatic processes using phosphorus as an energy source require magnesium for activation. [emedicine.medscape.com]

Epidemiology Hypophosphataemia is rare in the general population but relatively common in hospitalised patients (2.2-3.1%) and higher still in those on intensive care units (28.8-33.9%), those with sepsis (65-80%), those with chronic alcoholism (2.5-30.4% [patient.info]

Epidemiologic studies also show an association between magnesium deficiency and coronary artery disease (CAD). [emedicine.medscape.com]

Adami S, Marcocci C, Gatti D (2002) Epidemiology of primary hyperparathyroidism in Europe. J Bone Miner Res 17 Suppl 2: N18-23. Khan A, Bilezikian J (2000) Primary hyperparathyroidism: pathophysiology and impact on bone. CMAJ 163: 184-187. [omicsonline.org]

Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998; 32: S112–S119. pmid:9820470 View Article PubMed/NCBI Google Scholar 2. Blacher J,Guerin AP,Pannier B, Marchais SJ, London GM. [journals.plos.org]

Chapters 5-10 are more pathophysiologically oriented, and each contains an "appropriate mix" of basic and clinical information. [books.google.com]

Pathophysiological Mechanisms of Hypocalcemia Numerous conditions can cause hypocalcemia ( Table ). What follows is a review of some of the most common causes of hypocalcemia. [consultant360.com]

Pathophysiology  observed in patients with chronic secondary hyperparathyroidism and often after renal transplantation.  hypertrophied parathyroid glands fail to return to normal  continue to oversecrete despite serum calcium levels normal or elevated [slideshare.net]

Restless legs syndrome: pathophysiology and the role of iron and folate. Altern Med Rev. 2007 Jun;12(2):101-12. 9 Mitchell UH. Nondrug-related aspect of treating Ekbom disease, formerly known as restless legs syndrome. [womenshealthnetwork.com]

Khan A, Bilezikian J (2000) Primary hyperparathyroidism: pathophysiology and impact on bone. CMAJ 163: 184-187. Camanni F, Ghigo E Eds (2011) Malattie del sistema endocrino e del metabolismo - IV ed. Edi.Ermes, Milano. [omicsonline.org]

Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets [books.google.com]

Kumar A, Ralston SH (1996) Bisphosphonates prevent the hungry bone syndrome. Nephron 74: 729. [omicsonline.org]

There is insufficient data-based evidence on the best means to treat, minimise or prevent this severe complication of parathyroidectomy. [ncbi.nlm.nih.gov]

1. Brasier AR, Nussbaum SR. Hungry bone syndrome: clinical and biochemical predictors of its occurrence after parathyroid surgery. Am J Med. 1988; 84:654.
2. Hisham AN, Meah FA, Abdullah T, Khalid BAK, Sakinah 0, Tan TT. Hungry bone syndrome in a child following pararhyroid surgery. Asian] Surgery 1995; 18(2): 147-49.
3. Hurley K, Baggs D. Hypocalcemic cardiac failure in the emergency department. J Emerg Med. 2005 Feb. 28(2):155-9.
4. Kaye M, Somerville PJ, Lowe G, Ketis M, Schneider W. Hypocalcemic tetany and metabolic alkalosis in a dialysis patient: an unusual event. Am J Kidney Dis. 1997. Sep. 30(3):440-4.
5. Soffer D, Licht A, Yaar I, Abramsky O. Paroxysmal choreoathetosis as a presenting symptom in idiopathic hypoparathyroidism. J Neurol Neurosurg Psychiatry. 1977. Jul. 40(7):692-4.
6. Jesus, JE; Landry, A. Images in clinical medicine. Chvostek's and Trousseau's signs. The New England Journal of Medicine. 367 (11): e15.
7. Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336:1298.
8. Nijjer S, Ghosh AK, Dubrey SW. Hypocalcaemia, long QT interval and atrial arrhythmias. BMJ Case Reports. 2010.