A 5-year-old boy with global developmental delay presented with a 3-day history of vomiting, diarrhea, and refusing to bear weight. His parents said that he is a “picky eater,” with a diet consisting exclusively of orange soda, meat, and chili. His mother reported that he was having difficulty grasping objects and recently started biting his fingers. A physical examination revealed a very irritable, inconsolable child with diffuse muscle tenderness. The results of an extremity examination were consistent with carpal spasm, with a fully extended first finger with hyperextended distal interphalangeal joint, thumb constantly adducted to the hand, and last 3 digits mildly flexed and adducted together. The extremity examination also revealed twitching of facial muscles in response to tapping over area of facial nerve (ie, a positive Chvestok sign1). Laboratory studies confirm hypocalcemia (with a calcium level of 5.5 mg/dL [to convert to millimoles per liter, multiply by 0.25]), and a diagnosis of tetany is made. Additional physical examination findings include wrists that are unusually wide with prominent styloid processes of the radius and ulna; radiographs were abnormal (Figure, A and B).
Kelley SV, Jerardi KE. A 5-Year-Old Boy With Refractory Hypocalcemia. JAMA Pediatr. 2016;170(5):509-510. doi:10.1001/jamapediatrics.2015.2475