Lip Tremor in Hypocalcemia.

Neuromuscular hyperexcitability (NH) resulting from hypocalcemia commonly manifests as facial twitching and perioral tingling. 1 Lip tremor in hypocalcemia has never been reported to the best of our knowledge. We report a postpartum female, with two previous miscarriages, presenting with seizures and lip tremor and diagnosed with hypocalcemia.

A 23-year-old woman, 5 days postpartum with past history of two second-trimester miscarriages presented with new-onset generalized tonic–clonic seizures and lip tremor without fever, headache, or vomiting. Trousseau’s and Chvostek’s signs were positive, and neurological examination revealed a rhythmic, 8 to 10 Hz tremor involving upper lip ( Video 1 ). Computed tomography of the brain revealed bilateral basal ganglia, thalamus, subcortical white matter, red, and dentate nuclei calcification ( Fig. 1 ). Electroencephalogram was nonconclusive. Blood work-up revealed reduced calcium of 1.37 mmol/L (normal, 2.14–2.56), raised phosphate of 8.22 mg/dL (normal, 3–4.5), reduced parathyroid hormone of 4 pg/mL (normal, 12–88), and vitamin D of 9.55 ng/mL (normal, 10–55), thereby suggesting a diagnosis of idiopathic hypoparathyroidism. Gynecological and hematological investigations including anticardiolipin antibodies returned nonconclusive. We treated her initially with intravenous calcium gluconate followed by oral elemental calcium 2 g/d and calcitriol 1.5 g/d. Her symptoms including lip tremor subsided over subsequent 4 weeks ( Video 1 ).

Fig. 1

Noncontrast computed tomography of the brain showing calcifications in bilateral basal ganglia, thalamus, and subcortical white matter ( A ) and cerebellum ( B ).

Hypocalcemia is common in pregnancy, mostly due to hypoparathyroidism and dietary deficiency. 2 Long-standing idiopathic hypoparathyroidism was the cause in our case. NH resulting from reduced extracellular calcium modulates various receptors and ion channels, 3 commonly manifesting as muscle spasms, cramps, twitchings, paresthesia, numbness, and seizure. 1 Lip tremor in our case appears related to NH. NH may increase uterine irritability leading to miscarriages, 4 as reported by our case. Nearly 30 g of calcium is transferred from mother to the fetus throughout pregnancy with maximum in the last trimester. 2 4 Thus, long-standing hypocalcemia in pregnancy is more likely to manifest in the peripartum period as evidenced in our case. Asymptomatic hypocalcemia in pregnancy is widely prevalent in India, 5 and regular monitoring of serum calcium and a calcium-rich diet in pregnancy is essential.

Video 1

Video of our case shows positive Trousseau’s and Chvostek’s sign with upper lip tremor at presentation. The second segment of the video taken at 4 weeks after starting treatment shows absent trousseau’s and Chvostek’s sign with no upper lip tremor. Online content including video sequences viewable at:

https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0039-3399480.