# An Unusual Presentation of Multifactorial Hypocalcemia as Myopathy: A Case Report

## TL;DR

A 45-year-old woman with severe hypocalcemia presented with muscle weakness, and her condition improved after calcium and vitamin D treatment.

## Contribution

This case highlights hypocalcemic myopathy as a rare and under-recognized presentation of multifactorial hypocalcemia.

## Key findings

- The patient showed proximal muscle weakness and elevated creatine kinase due to severe hypocalcemia.
- Hypocalcemia was caused by hypoparathyroidism, vitamin D deficiency, sepsis, and transfusion-related citrate load.
- Intravenous calcium and vitamin D treatment led to significant clinical improvement and near-complete recovery.

## Abstract

Hypocalcemia is a common metabolic disturbance with a broad spectrum of clinical presentations, ranging from asymptomatic laboratory findings to severe, life-threatening complications. While neuromuscular irritability is a well-known feature, myopathy as a primary presentation is rare and often under-recognized. We report the case of a 45-year-old female with type 2 diabetes and hypertension who presented with progressive lower limb weakness and generalized body aches. She had a recent history of an abdominal skin abscess and had received blood transfusions without calcium correction. On examination, she demonstrated significant proximal muscle weakness and elevated serum creatine kinase levels. Laboratory investigations revealed severe hypocalcemia (serum calcium 4.5 mg/dL), low vitamin D, and inappropriately low-normal parathyroid hormone (PTH) levels. ECG showed QTc prolongation and anteroseptal injury pattern. A diagnosis of hypocalcemic myopathy secondary to idiopathic hypoparathyroidism, compounded by vitamin D deficiency, sepsis, and transfusion-related citrate load, was made.

The patient was treated with intravenous calcium gluconate, vitamin D supplementation, and antibiotics. Her muscle strength gradually improved with normalization of calcium levels. She was discharged on oral calcium and calcitriol, and showed near-complete recovery at the two-week follow-up. This report highlights the importance of considering hypocalcemia in patients presenting with myopathy. Multiple contributing factors can coexist and exacerbate calcium deficiency in these patients. Early recognition and prompt correction are essential to prevent long-term neuromuscular complications.