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Hungry Bones Syndrome

'Hungry Bone' Syndrome

Hungry bones syndrome is a disorder characterized by significant and persistent hypocalcemia, even though serum parathormone levels may be normal or even augmented. This disorder occurs following an increase of the bone formation to bone resorption ratio, a state which leads to the abundant amount of calcium than that required by the organism.


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.

  • […] 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]
Vascular Disease
  • diseases of the kidney 283 Hemolytic uremic syndrome and thrombotic thrombocytopenic purpura 297 Renal involvement in dysproteinemias 314 The hyperuricemic nephropathies 327 Therapy of renal disorders in liver disease 334 The management of renal insufficiency[books.google.com]
Biliary Colic
  • Intestinal and biliary colic can also occur as a result of hypocalcemia, as can hemiballism, parkinsonism, and choreoathetosis. The physical examination for hypocalcemia includes the Chvostek and Trousseau signs.[symptoma.com]
  • […] infections 221 Vesicoureteral reflux and reflux nephropathy 234 Management of genitourinary tuberculosis 255 Vasculitic diseases of the kidney 273 Noninflammatory vascular diseases of the kidney 283 Hemolytic uremic syndrome and thrombotic thrombocytopenic purpura[books.google.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]
  • Following the removal of the mass and decrease in parathormone levels, the patient suffered from a prolonged period of hypocalcemia and his bone pain worsened.[ncbi.nlm.nih.gov]
  • Oncogenic osteomalacia is a paraneoplastic syndrome of osteomalacia, hypophosphataemia, renal phosphate loss, bone pain, and muscle weakness.[patient.info]
  • Hyperparathyroidism Thyroid and parathyroid Specialty Endocrinology Symptoms None, kidney stones, weakness, depression, bone pains, confusion, increased urination [1] [2] [3] Complications Osteoporosis [2] [3] Usual onset 50 to 60 [2] Types Primary, secondary[en.wikipedia.org]
  • Indications for surgery  bone pain or fracture  Pruritus  Calciphylaxis  Extraskeletal nonvascular calcifications  elevated parathyroid hormone levels despite appropriate medical therapy  severe hyperparathyroidism  persistent serum levels of intact[slideshare.net]


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]


  • The clinical features and treatment of hyperparathyroidism in renal transplant recipients are discussed, as are diagnosis, pathogenesis, and management of hungry bone syndrome.[ncbi.nlm.nih.gov]
  • 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]
  • Treatment is aimed at replenishing the severe calcium deficit by using high doses of calcium supplemented by high doses of active metabolites of vitamin D.[ncbi.nlm.nih.gov]


  • 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]


  • 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]


  • 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]
  • 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]
Sex distribution
Age distribution


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


  • 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]
  • There is insufficient data-based evidence on the best means to treat, minimise or prevent this severe complication of parathyroidectomy.[ncbi.nlm.nih.gov]
  • Kumar A, Ralston SH (1996) Bisphosphonates prevent the hungry bone syndrome. Nephron 74: 729.[omicsonline.org]



  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.

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Last updated: 2018-06-22 02:08