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Chvostekrsquos sign a video demonstration

Sadishkumar Kamalanathan1 Karthik Balachandran1 Girish Parthan1 Abdoul Hamide2

1Department of Endocrinology Jawaharlal Institute of Post Graduate Medical Education and Research Puducherry India2Department of Medicine Jawaharlal Institute of Post Graduate Medical Education and Research ( JIPMER) Pondicherry India

Correspondence to Dr Sadishkumar Kamalanathan sadishkkgmailcom

DESCRIPTIONA 53-year-old lady was referred to the Endocrinologydepartment of our institute for management of postsur-gical metabolic complaints following near total thyroi-dectomy done elsewhere for obstructive nodular goitre2 weeks back She was started on thyroxine of 150 mcgand calcium of 3 g in divided doses postoperatively Herclinical evaluation showed her to have positiveChvostekrsquos (video 1) and delayed Trousseaursquos sign Hercalcium was documented to be 14 mmoll (normalrange (NR) 2ndash25) phosphate 24 mmoll (NR 08ndash15)and iPTH 05 pmoll (NR 12ndash58) Her fT4 was 122pmoll (NR 103ndash232) and thyroid stimulatinghormone was 38 mIUl (NR 05ndash45) Her biopsy wasconfirmed to be nodular goitre Postsurgical hypothy-roidism with hypoparathyroidism was diagnosed Shewas additionally started on calcitriol (025 mcg twicedaily) and calcium dose modified (2 g in divided doses)and soon her Chvostekrsquos sign resolved High dosesof calcium may not be sufficient in the management ofhypoparathyroidism and often requires addition ofactive vitamin D

Chvostekrsquos sign was attributed initially to increasedsensitivity of the facial nerve to mechanical stimuli inidiopathic epidemic tetany1 2 Traditionally it is elicitedby tapping on the face at a point just anterior to the earand just below the zygomatic bone3 A positive responseis represented by twitching of the ipsilateral facialmuscles suggesting neuromuscular excitability caused byhypocalcaemia Although classically described with hypo-calcaemia due to hypoparathyroidism it is also elicited insome young healthy children and alkalotic states asduring vomiting and hyperventilation It is very easy totest in clinical practice compared with Trousseaursquos signand hence its clinical significance

Learning points

A positive Chvostekrsquos sign represents increasedneuromuscular excitability caused by hypocalcaemia

It can be even elicited in some young healthy childrenand alkalotic states following vomiting andhyperventilation

Resolution of Chvostekrsquos sign occurs with effectivetreatment of hypoparathyroidism with calcium andactive vitamin D

Competing interests None

Patient consent Obtained

REFERENCES1 Krogh L Wynne JM Cywes S The value of Chvostekrsquos sign in tetany

S Afr Med J 196842846ndash72 Kugelberg E The mechanism of chvostekrsquos sign AMA Arch Neurol

Psychiatry 195165511ndash173 Hoffman E The Chvostek sign a clinical study Am J Surg 19589633ndash7

Video 1 Video clip demonstrating Chvostekrsquos sign inpost-thyroidectomy patient

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Kamalanathan S Balachandran K Parthan G Hamide A Chvostekrsquos sign a video demonstration BMJ Case Reports 2012101136bcr-2012-007098Published XXX

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2 of 2 BMJ Case Reports 2012 doi101136bcr-2012-007098

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J Case R

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