Spontaneous bilateral carpopedal spasm in a bulimic patient

Description

A 36-year-old woman presented to the emergency department after she woke up with painful spasm of bilateral hands. She had been vomiting 10–15 times daily for the past few days. She denied any laxative or diuretic abuse. She had 18-year history of bulimia nervosa, primarily involving self-induced vomiting and excessive exercising. Her body mass index was 20.7 kg/m². Vital signs and physical examination were unremarkable except for dry oral mucosa, poor oral dentition and classic bilateral carpopedal spasm (figure 1). Labs revealed hypocalcaemia (ionised calcium 0.88 mmol/L), hypokalaemia (potassium 2.8 mEq/L), hypomagnesaemia (magnesium 1.6 mEq/L), metabolic alkalosis (serum bicarbonate 34.5 mEq/L), hypochloraemia (chloride 78 mEq/L), hypophosphataemia (phosphorus 1.6 mg/dL), acute kidney injury (serum creatinine 2.49 mg/dL, baseline of 0.9), leucocytosis (white blood cells 15 700  x10⁹/L mm³) and normal serum albumin 4 g/dL. ECG showed normal sinus rhythm with prolonged QTc of 550 ms (figure 2). Urine drug screen was positive...

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