Calcium, magnesium, and psychotic symptoms in a girl with idiopathic hypoparathyroidism

The Role and the Effect of Magnesium in Mental Disorders: A Systematic Review

Introduction: Magnesium is an essential cation involved in many functions within the central nervous system, including transmission and intracellular signal transduction. Several studies have shown its usefulness in neurological and psychiatric diseases. Furthermore, it seems that magnesium levels are lowered in the course of several mental disorders, especially depression. Objectives: In this study, we wish to evaluate the presence of a relationship between the levels of magnesium and the presence of psychiatric pathology as well as the effectiveness of magnesium as a therapeutic supplementation. Methods: A systematic search of scientific records concerning magnesium in psychiatric disorders published from 2010 up to March 2020 was performed. We collected a total of 32 articles: 18 on Depressive Disorders (DD), four on Anxiety Disorders (AD), four on Attention Deficit Hyperactivity Disorder (ADHD), three on Autism Spectrum Disorder (ASD), one on Obsessive–Compulsive Disorder (OCD), one on Schizophrenia (SCZ) and one on Eating Disorders (ED). Results: Twelve studies highlighted mainly positive results in depressive symptoms. Seven showed a significant correlation between reduced plasma magnesium values and depression measured with psychometric scales. Two papers reported improved depressive symptoms after magnesium intake, two in association with antidepressants, compared to controls. No significant association between magnesium serum levels and panic or Generalized Anxiety Disorder (GAD) patients, in two distinct papers, was found. In two other papers, a reduced Hamilton Anxiety Rating Scale (HAM-A) score in depressed patients correlated with higher levels of magnesium and beneficial levels of magnesium in stressed patients was found. Two papers reported low levels of magnesium in association with ADHD. Only one of three papers showed lower levels of magnesium in ASD. ED and SCZ reported a variation in magnesium levels in some aspects of the disease. Conclusion: The results are not univocal, both in terms of the plasma levels and of therapeutic effects. However, from the available evidence, it emerged that supplementation with magnesium could be beneficial. Therefore, it is necessary to design ad hoc clinical trials to evaluate the efficacy of magnesium alone or together with other drugs (antidepressants) in order to establish the correct use of this cation with potential therapeutic effects.

Signs and Symptoms of Hypoparathyroidism

Hypoparathyroidism is associated with a spectrum of clinical manifestations in the acute and chronic settings, from mild to debilitating. Although the acute symptoms of hypocalcemia are primarily due to neuromuscular irritability, the chronic manifestations of hypoparathyroidism may be due to the disease itself or to complications of therapy or to both. The chronic complications of hypoparathyroidism can affect multiple organ systems, including the renal, neurologic, neuropsychiatric, skeletal, and immune systems. Further research is needed to determine the pathophysiology of complications in hypoparathyroidism and whether interventions can decrease the risk of these complications.

Magnesium in schizophrenia

Many psychopathological symptoms, including schizophrenia, can be associated with magnesium metabolism disturbances. In the literature, contradictory data exist regarding magnesium levels in patients with this disorder. However, this situation might be caused by determination of extracellular concentration of magnesium; although, this is mainly an intracellular ion. There are no data concerning determination of the ionized fraction of magnesium in patients with schizophrenia, while the ionized fraction represents 67% of the total pool of magnesium in healthy people. Also, the mechanism of magnesium action-the effect of magnesium ions on NMDA and GABA receptors-has not yet been fully investigated. There are preliminary studies aimed at increasing the effectiveness of schizophrenia pharmacotherapy via magnesium supplementation. Multidirectional activity of magnesium can significantly increase its therapeutic effect in psychiatry. This observation is confirmed by recent studies conducted by various research teams. However, further studies on the role of magnesium supplementation in patients with schizophrenia are needed.

Hypocalcemia Masquerading as Schizophreniform Disorder

Among the symptoms of hypocalcemia, tetany, papilledema, and seizures may occur in patients who develop hypocalcemia acutely. We describe a rare case of hypocalcemia presenting as schizophreniform disorder. Among other presentations of hypocalcemia, one should also look for the relation between psychotic symptoms and calcium levels in a patient presenting with psychotic symptoms.

Clinical manifestations and frequency of hypocalcemia in 22q11.2 deletion syndrome

BACKGROUND

This study investigated the evolution of hypocalcemia with age and its associated risk factors in patients with 22q11.2 deletion syndrome (22qDS) and congenital heart defects.

METHOD

A retrospective review of the medical records of 16 22qDS patients (nine female, seven male; age range, 20.5-43 years) was performed. The frequency of hypocalcemia, as well as the clinical course of the disease and the presence of other phenotypes, were investigated.

RESULTS

Ten of the 16 patients (62.5%) had a history of hypocalcemia. Among the 10 patients, the first onset of hypocalcemia occurred in the following developmental periods: neonatal stage, n = 1; early childhood, n = 3; late childhood, n = 2; adolescence, n = 2; and adulthood, n = 2. Neonatal hypocalcemia was observed in one patient, but it was transient. Two patients had sustained hypocalcemia after cardiac surgery. Hypocalcemia in one patient was transient following cardiac surgery, but it recurred during early adulthood. One patient developed hypocalcemia at 43 years of age. Thymus defect tended to be correlated with history of hypocalcemia (P = 0.09). This condition was often transient (60%) and was triggered by physical stress, such as intracardiac surgery.

CONCLUSION

In 22qDS patients, hypocalcemia was often mild and transient during childhood, but it may recur in adulthood. Routine clinical measurement of serum calcium is recommended, particularly in 22qDS patients with thymic defect or in patients who are under physical stress.

Court orders on procreation

OBJECTIVE

The aim of this study is to empirically evaluate judgments entered from 1913 to 2013 in the matters of compulsory sterilization.

METHODS

Holdings and dispositions at the U.S. Appellate and Supreme courts are randomly located in LexisNexis using Shepard's symbols. Continuous variables are processed with the Mantel-Haenszel method. Court orders are used as units of analysis.

RESULTS

The majority of cases (56.4 %) concern minors at a mean age of 11.7 years. Forty-four (80 %) petitions are filed by the parents or guardians; 11 (20 %) are parens patriae. Petitions for female sterilization are denied in 56.4 % cases under the Federal Laws (2 U.S.C. 431; 28 U.S.C; 29 U.S.C; 42 U.S.C; 424 U.S.), Procedural due process clause of the 14th Amendment, statutes, and common law precedents. Petitions for female sterilization are granted in 36.4 % cases under the statutory penal codes, the Law of the land, precedents, and the dicta. No significant associations are found between the parity and degree of mental impairment (r = 0.342). Substantial correlations are met between the gender, degree of impairment (r (2) = 0.724), and dispositions (r (2) = 802). The mean age of women is 20.78 years; the mean age of men is 30.25 years. Correlations fail to establish reasoning between the age of the subjects and the entered judgments (r (2) = 0. 356).

CONCLUSIONS

(1) The female/male ratio (8:1) and age gap of the respondents indicate on a disproportionate impact of the statutes. (2) The procedure of sterilization in itself is incommensurate with equality, as the volume of surgery is uneven in males and females. (3) The case law is instructive with respect to which arguments have not been advanced. (4) Lastly, due to the etiological intricacy of mental impairment, with genetic transmission strikingly different in men and women, expert-witnesses ought to act in a medical vacuum because there is no mathematical certainty as to the transmission mode of the traits in question (exon and intron mutations, triplet repeat disorders, histone disorders, autosomal-dominant or autosomal-recessive transmission, sex chromosome-linkage, polygenomic imprinting, and organic reasons).

Organic anxiety in a woman with breast cancer receiving denosumab

Hypocalcemia can induce heterogeneous psychiatric manifestations, and its etiology can be multifactorial. Herein, we describe a patient who had previously undergone resection of parathyroid glands, who presented with extreme anxiety and hypocalcemia after denosumab treatment for cancer-related bone metastasis. The anxiety subsided soon after correction of her serum calcium level. When denosumab is prescribed for patients with predisposing factors of hypocalcemia, such as hypoparathyroidism, clinicians should be aware of symptomatic hypocalcemia.

Mood disorder as a manifestation of primary hypoparathyroidism: a case report

Introduction

Primary hypoparathyroidism is a rare condition caused by parathyroid hormone deficiency and characterized by hypocalcemia. The clinical manifestations of primary hypoparathyroidism include tetany, seizures, paresthesias, dementia, and parkinsonism. Psychiatric manifestations such as mood disorders are unusual and may constitute a major diagnostic challenge, especially if the typical manifestations caused by hypocalcemia are absent.

Case presentation

The patient was a 22-year-old Caucasian man with a history of chronic omeprazole use and periodic seizures, who presented to the emergency department of a secondary hospital in Southern Brazil with symptoms of major depression (sadness, anhedonia, loss of appetite, insomnia, and fatigue) associated with paresthesias affecting his toes. The initial electrocardiogram revealed a prolonged QTc interval. A computed tomography scan of his brain revealed bilateral, nonenhancing hyperdense calcifications involving the putamen and caudate nucleus. An electroencephalogram showed generalized bursts of slow spikes. Blood laboratory study results indicated serum hypocalcemia, hypomagnesemia, and hyperphosphatemia associated with a low parathyroid hormone level. His serum levels of albumin, 25-hydroxyvitamin D, thyroid-stimulating hormone, T3 and T4 thyroid hormones, as well as the results of kidney function tests, were normal. The definitive diagnosis was primary hypoparathyroidism with psychiatric manifestations due to chronic hypomagnesemia induced by proton pump inhibitor use.

Conclusions

In some cases, to differentiate between a primary psychiatric disorder and primary hypoparathyroidism with neuropsychiatric symptoms may represent a challenge given that the classical manifestations of hypocalcemia, especially tetany, may be absent in the setting of chronic hypoparathyroidism. Clinicians and psychiatrists should consider primary hypoparathyroidism part of the differential diagnosis during the evaluation of patients with mood symptoms, especially in the context of atypical presentations associated with hypocalcemia.

Prevalence of Hypoparathyroidism (HPT) in Beta Thalassemia Major

INTRODUCTION

The aim of this study was to assess the parathyroid functions and bone mineral density (BMD) in patients with beta thalassemia and to correlate them with serum ferritin, calcium, phosphorus and alkaline phosphatase levels.

MATERIALS AND METHODS

This is a case control study which was done on 55 subjects (40 cases and 15 controls) in the age group of 2-18 years. The cases included were with confirmed diagnosis of beta thalassemia major, more than ten blood transfusions and serum ferritin levels >2000 μg/L irrespective of chelation therapy.

RESULTS

Significant Hypoparathyroidism (HPT) observed along with low BMD levels in beta thalassemia patients (p < 0.01). A significant decrease in serum calcium level was seen in cases when compared to controls, where as the levels of both serum phosphorus and alkaline phosphatase levels increased in cases when compared to controls.

CONCLUSION

BMD and PTH levels are very useful tools for diagnosing HPT. As a routine, in beta thalassemia major, screening for vitamin D deficiency and hypocalcemia should be done in second decade of life and as a preventive measure they should be supplemented with calcium and vitamin D to prevent hypocalcemic tetany, to facilitate bone growth and to prevent fractures.

CaSR-mediated interactions between calcium and magnesium homeostasis in mice

Calcium (Ca) and magnesium (Mg) homeostasis are interrelated and share common regulatory hormones, including parathyroid hormone (PTH) and vitamin D. However, the role of the calcium-sensing receptor (CaSR) in Mg homeostasis in vivo is not well understood. We sought to investigate the interactions between Mg and Ca homeostasis using genetic mouse models with targeted inactivation of PTH (PTH KO) or both PTH and the calcium-sensing receptor (CaSR) (double knockout, DKO). Serum Mg is lower in PTH KO and DKO mice than in WT mice on standard chow, whereas supplemental dietary Ca leads to equivalent Mg levels for all three genotypes. Mg loading increases serum Mg in all genotypes; however, the increase in serum Mg is most pronounced in the DKO mice. Serum Ca is increased with Mg loading in the PTH KO and DKO mice but not in the WT mice. Here, too, the hypercalcemia is much greater in the DKO mice. Serum and especially urinary phosphate are reduced during Mg loading, which is likely due to intestinal chelation of phosphate by Mg. Mg loading decreases serum PTH in WT mice and increases serum calcitonin in both WT and PTH KO mice but not DKO mice. Furthermore, Mg loading elevates serum 1,25-dihydroxyvitamin D in all genotypes, with greater effects in PTH KO and DKO mice, possibly due to reduced levels of serum phosphorus and FGF23. These hormonal responses to Mg loading and the CaSR's role in regulating renal function may help to explain changes in serum Mg and Ca found during Mg loading.

Secondary psychoses: an update

Psychotic disorders due to a known medical illness or substance use are collectively termed secondary psychoses. In this paper, we first review the historic evolution of the concept of secondary versus primary psychosis and how this distinction supplanted the earlier misleading classification of psychoses into organic and functional. We then outline the clinical features and approach to the diagnosis of secondary psychotic disorders. Features such as atypical presentation, temporal relation to detectable medical cause, evidence of direct physiological causal relationship to the etiological agent, and the absence of evidence of a primary psychotic illness that may better explain the presentation suggest consideration of a secondary psychosis. Finally, we discuss how careful studies of secondary psychotic disorders can help elucidate the pathophysiology of primary, or idiopathic, psychotic disorders such as schizophrenia. We illustrate this issue through a discussion of three secondary psychotic disorders - psychoses associated with temporal lobe epilepsy, velocardiofacial syndrome, and N-methyl D-aspartate (NMDA) receptor encephalitis - that can, respectively, provide neuroanatomical, genetic, and neurochemical models of schizophrenia pathogenesis.

Evaluation and treatment of children and adolescents with psychotic symptoms

In recent years, there have been increasing efforts to develop early detection and prevention strategies for patients at risk of the development of psychotic disorders. These efforts have led to improved recognition and characterization of psychotic symptoms in youth. This review focuses on the evaluation of children and adolescents with psychotic symptoms who are experiencing functional impairment but who do not meet current criteria for schizophrenia. For this article, emphasis is placed on the evaluation of symptoms, differential diagnosis, and consideration of potential interventions.

3D-QSAR study indicates an enhancing effect of membrane ions on psychiatric drugs targeting serotonin receptor 5-HT1A

Antidepressants and antipsychotics are psychiatric agents used for the treatment of various types of psychiatric diseases. Although currently among the most commonly prescribed drugs, their effectiveness and adverse effects are the topic of many studies and controversial claims. Here we generate QSAR models based on compounds series including 20 drugs recommended for two critical psychiatric diseases: depression and schizophrenia and we use these QSAR models to predict the biological activity of these 20 antidepressants and antipsychotics. We establish the membrane ions' contributions (sodium, potassium, calcium and iron) mediated by water to the antagonism of these drugs at the 5-HT1A receptor. The reliability of our QSAR models in predicting compounds activity is indicated by significant values for cross-validated correlation q² (0.60-0.76) and fitted correlation r² (0.96-0.98) coefficients. Our results indicate that potassium, calcium and iron play a key role for the antagonistic activity of drugs at the 5-HT1A receptor. Moreover, based on the established QSAR equations, we analysed 24 new escitalopram derivatives as possibly improved antidepressants targeting the 5-HT1A receptor. We identified that the presence of methyl groups and hydrogen atoms improves antidepressant activity while the simultaneous presence of ethyl, propyl or halogens decreased drastically antidepressant activity at the 5-HT1A site.

Hypoparathyroidism in transfusion-dependent patients with beta-thalassemia

Hypoparathyroidism is thought to be a rare consequence of iron overload seen in beta-thalassemic transfused patients. This study was conducted to determine the prevalence of hypoparathyroidism in a large number of beta-thalassemic patients, and its potential correlation with the presence of other endocrinopathies caused by iron overload. Serum and urine biochemical parameters were measured in 243 thalassemic patients (136 females and 107 males) in order to determine the prevalence of hypoparathyroidism and evaluate bone turnover. The patients were divided into two groups according to the presence of hypoparathyroidism. We compared the prevalence of other endocrinopathies and disease complications in the two groups. Hypoparathyroidism was detected in 13.5% of the patients (33 subjects; 17 males and 16 females). Serum-intact parathyroid hormone, and total and ionized calcium were significantly lower, while phosphorus was significantly higher in thalassemic patients with hypoparathyroidism. The reduction in BMD was more prominent in normal thalassemic patients (Z score = -2.246 +/- 0.97) compared with those with hypoparathyroidism (Z score = -1.975 +/- 0.89), although the difference was not statistically significant. Disturbed glucose metabolism was more common in patients with hypoparathyroidism (P < 0.05). In addition, heart dysfunction was statistically more frequent in this group (odds ratio = 2.51, P < 0.05). Hypoparathyroidism is a not infrequently observed complication in thalassemic patients. Since the concentration of ferritin is not a valuable tool in the prediction of the development of hypoparathyroidism, parathyroid function should be tested periodically, particularly when other iron overload-associated complications occur.

Neuroleptic Malignant Syndrome after Haloperidol and Fentanyl Infusion in a Patient with Cancer with Severe Mineral Imbalance

This case report describes a terminally ill patient with cancer with severe hypophosphataemia, hypocalcemia, and hypomagnesemia who developed neuroleptic malignant syndrome after administration of a combination of haloperidol and fentanyl. The chief etiology of neuroleptic malignant syndrome in this patient was administration of haloperidol, but fentanyl and coexisting mineral imbalance could have contributed to development of the syndrome. Palliative care clinicians should be aware that neuroleptic malignant syndrome can occur in their patients receiving haloperidol.

Psychiatric aspects of parathyroid disease

Parathyroid diseases can present with psychiatric symptoms and can be recognized through determinations of serum electrolytes, especially the calcium level. Psychiatric evaluations should include a serum calcium concentration test, which is also essential in reassessment of patients poorly responsive to mental illness treatment. A magnesium and a phosphate assay may also be diagnostically helpful. Abnormality of divalent cation levels may provide evidence for consideration of, or ruling out, parathyroid disorders. Determinations of parathyroid hormone are performed if clinically indicated, and if abnormal divalent cation quantifications are confirmed. If parathyroid disease is identified, corrective endocrine therapies may diminish or even cure psychiatric aspects of parathyroid pathology. Failure to recognize a parathyroid disorder leaves an endocrine-induced mental dysfunction without proper treatment.