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de causa metab&#243;lica ou t&#243;xica &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">O c&#225;lcio tem uma fun&#231;&#227;o fulcral no metabolismo mioc&#225;rdico&#44; sendo reconhecido que a hipocalcemia reduz a contratilidade mioc&#225;rdica&#46; Contudo&#44; a incid&#234;ncia de insufici&#234;ncia card&#237;aca associada a esta etiologia &#233; rara&#44; encontrando-se descritos apenas poucos casos na literatura mundial<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Na maioria dos casos descritos verificou-se uma rela&#231;&#227;o entre a corre&#231;&#227;o da hipocalcemia e a resolu&#231;&#227;o da insufici&#234;ncia card&#237;aca&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Na literatura portuguesa apenas se encontra descrito um caso de miocardiopatia dilatada associada a hipotiroidismo p&#243;s-cir&#250;rgico&#44; mas tendo como fator descompensante para a insufici&#234;ncia card&#237;aca a hipocalcemia&#44; tamb&#233;m no contexto de hipoparatiroidismo p&#243;s-cir&#250;rgico<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Caso cl&#237;nico</span><p id="par0025" class="elsevierStylePara elsevierViewall">Doente do sexo feminino de 60 anos de idade&#44; natural do Brasil &#40;onde exercia a profiss&#227;o de professora de matem&#225;tica&#41; e residente em Portugal h&#225; cerca de um ano &#40;onde trabalhava como empregada de limpeza&#41;&#44; com antecedentes pessoais conhecidos por pseudofaquia bilateral&#44; objeto de cirurgia h&#225; mais de 15 anos&#46; Negava quaisquer outras patologias pr&#233;vias &#40;entre as quais&#44; fatores de risco cardiovascular&#41;&#44; tal como a toma de medica&#231;&#227;o em ambulat&#243;rio&#44; h&#225;bitos et&#237;licos ou tab&#225;gicos e antecedentes familiares relevantes&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Estava assintom&#225;tica at&#233; tr&#234;s meses antes do internamento&#44; altura em que come&#231;ou a referir dispneia de esfor&#231;o de agravamento progressivo&#44; a que se associou&#44; nos 3&#160;d pr&#233;vios &#224; admiss&#227;o hospitalar&#44; a ortopneia&#46; Durante todo este per&#237;odo&#44; negava dispneia parox&#237;stica noturna&#44; dor tor&#225;cica&#44; palpita&#231;&#245;es&#44; s&#237;ncope&#44; tosse&#44; expetora&#231;&#227;o e febre&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Por queixas para m&#237;nimos esfor&#231;os recorreu ao Servi&#231;o de Urg&#234;ncia&#44; onde &#224; observa&#231;&#227;o se destacavam confus&#227;o mental&#44; lentifica&#231;&#227;o psicomotora e f&#225;cies depressiva&#44; PA de 97&#47;59<span class="elsevierStyleHsp" style=""></span>mmHg&#44; pulso de 79<span class="elsevierStyleHsp" style=""></span>bpm &#40;r&#237;tmico&#41;&#44; FR de 28<span class="elsevierStyleHsp" style=""></span>cpm&#44; rarefa&#231;&#227;o do ter&#231;o externo das sobrancelhas&#44; tremor das extremidades e fascicula&#231;&#245;es&#44; mas sem sinal de Chvostek ou de Trousseau&#46; Eram aud&#237;veis fervores crepitantes na metade inferior de ambos os hemit&#243;raxes e galope de S3&#44; com sopro sist&#243;lico grau <span class="elsevierStyleSmallCaps">i&#47;vi</span> mais aud&#237;vel na &#225;rea mitral&#46; O restante exame objetivo era normal&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A avalia&#231;&#227;o complementar inicial revelava marcadores de necrose mioc&#225;rdica normais&#44; BNP elevado&#44; rabdomi&#243;lise&#44; hipocalcemia grave e insufici&#234;ncia respirat&#243;ria tipo um &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46; O eletrocardiograma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41; evidenciava prolongamento do intervalo QT &#40;QTc 0&#44;53&#160;s&#41; e invers&#227;o das ondas T de V2 a V4 e DI&#46; A telerradiografia p&#243;stero-anterior do t&#243;rax &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#41; evidenciava infiltrado intersticial no ter&#231;o inferior de ambos os campos pulmonares&#44; sugestivo de edema&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">O ecocardiograma efetuado na urg&#234;ncia &#224; &#171;cabeceira da doente&#187; mostrava dilata&#231;&#227;o do ventr&#237;culo esquerdo &#40;60&#47;44<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; com hipocontratilidade difusa &#40;mais acentuada no segmento apical&#41;&#44; fun&#231;&#227;o sist&#243;lica global moderadamente comprometida &#40;fra&#231;&#227;o de encurtamento de 26&#37;&#41;&#44; sem altera&#231;&#245;es valvulares ou derrame peric&#225;rdico &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#41;&#46; A tomografia computorizada &#40;TC&#41; tor&#225;cica de alta resolu&#231;&#227;o foi de baixa probabilidade para tromboembolismo pulmonar&#46; As serologias para discriminar agentes infecciosos frequentemente implicados na miocardite e doen&#231;a de Chagas foram negativas&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Iniciou tratamento sintom&#225;tico da insufici&#234;ncia card&#237;aca com diur&#233;tico&#44; inibidores da enzima de convers&#227;o da angiotensina e nitratos&#44; com resultados pouco satisfat&#243;rios em termos sintom&#225;ticos&#44; e prosseguiu-se com a investiga&#231;&#227;o complementar da hipocalcemia&#46; A esta associava-se hipocalci&#250;ria e hiperfosfatemia&#44; no contexto da diminui&#231;&#227;o de hormona paratiroideia identificada &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46; A investiga&#231;&#227;o etiol&#243;gica do hipoparatiroidismo excluiu as causas neopl&#225;sica&#44; infiltrativa&#44; poliglandular ou autoimune&#44; pelo que se concluiu o diagn&#243;stico de hipoparatiroidismo idiop&#225;tico&#46; A ecografia renal n&#227;o revelou altera&#231;&#245;es e a TC cranioencef&#225;lica &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figura 4</a>&#41; demonstrou extensas calcifica&#231;&#245;es supratentoriais &#40;mais evidentes ao n&#237;vel dos g&#226;nglios da base&#41;&#44; sugestivas de cronicidade do hipoparatiroidismo&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Com os diagn&#243;sticos presuntivos de insufici&#234;ncia card&#237;aca de etiologia n&#227;o esclarecida e hipocalcemia secund&#225;ria a hipoparatiroidismo idiop&#225;tico continuou a referida medica&#231;&#227;o&#44; a que se associou carbonato de c&#225;lcio endovenoso&#44; quelante do f&#243;sforo &#40;sevelamero&#41; e vitamina D&#44; com o que se verificou a normaliza&#231;&#227;o progressiva do metabolismo fosfoc&#225;lcico&#44; acompanhada da completa reversibilidade dos sintomas de insufici&#234;ncia card&#237;aca&#44; bem como da normaliza&#231;&#227;o do eletro e ecocardiograma &#40;ventr&#237;culo esquerdo com 50&#47;32<span class="elsevierStyleHsp" style=""></span>mm&#44; sem altera&#231;&#245;es da contratilidade e fra&#231;&#227;o de encurtamento de 36&#37;&#41;&#46; Nesta altura manteve-se a terap&#234;utica do hipoparatiroidismo e suspendeu-se a administra&#231;&#227;o de diur&#233;ticos&#44; nitratos e inibidores da enzima de convers&#227;o da angiotensina&#44; mantendo-se a doente assintom&#225;tica&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Efetuou&#44; ent&#227;o&#44; cateterismo card&#237;aco&#44; que demonstrou aus&#234;ncia de les&#245;es coron&#225;rias significativas e normalidade da fun&#231;&#227;o ventricular esquerda &#40;fra&#231;&#227;o de eje&#231;&#227;o de 64&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A associa&#231;&#227;o entre a corre&#231;&#227;o da hipocalcemia e o desaparecimento da insufici&#234;ncia card&#237;aca&#44; na aus&#234;ncia de etiologia alternativa para esta s&#237;ndrome&#44; permitem afirmar o hipoparatiroidismo &#40;e consequente hipocalcemia&#41; como a causa da insufici&#234;ncia card&#237;aca congestiva&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discuss&#227;o</span><p id="par0070" class="elsevierStylePara elsevierViewall">A regula&#231;&#227;o dos n&#237;veis s&#233;ricos de c&#225;lcio depende essencialmente da hormona paratiroideia &#40;PTH&#41;&#44; quer pela a&#231;&#227;o a curto prazo na reabsor&#231;&#227;o &#243;ssea ou renal &#40;no t&#250;bulo contornado distal&#41; de c&#225;lcio&#44; quer por adapta&#231;&#227;o a longo prazo&#44; dependente da estimula&#231;&#227;o da produ&#231;&#227;o renal de vitamina D<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">O c&#225;lcio &#233; essencial ao automatismo card&#237;aco e ao acoplamento excita&#231;&#227;o - contra&#231;&#227;o do mioc&#225;rdio&#44; tornando-o fundamental para uma fun&#231;&#227;o card&#237;aca normal&#46; A entrada de c&#225;lcio na fibra mioc&#225;rdica induz a liberta&#231;&#227;o do c&#225;lcio presente no reticulo sarcoplasm&#225;tico&#44; ampliando a concentra&#231;&#227;o de c&#225;lcio intracelular&#44; que&#44; por sua vez&#44; se liga &#224; troponina C&#44; permitindo a intera&#231;&#227;o entre a actina e a miosina e consequente contra&#231;&#227;o muscular<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As manifesta&#231;&#245;es cl&#237;nicas da hipocalcemia aguda resultam essencialmente de irritabilidade neuromuscular exacerbada&#44; expressa por parestesias e tremor das extremidades&#44; rabdomi&#243;lise&#44; c&#227;ibras e espasmos carpopedais&#46; S&#227;o frequentemente demonstrados sinais de tetania latente pela execu&#231;&#227;o das manobras de Chvostek e Trousseau&#46; A hipocalcemia pode ainda cursar com manifesta&#231;&#245;es neuropsiqui&#225;tricas&#44; como irritabilidade e depress&#227;o<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">9&#44;10</span></a>&#44; o que pode justificar a lentifica&#231;&#227;o psicomotora e confus&#227;o da doente&#46; Esta apresentava ainda rarefa&#231;&#227;o do ter&#231;o externo das sobrancelhas&#44; um sinal t&#237;pico de hipotiroidismo &#40;n&#227;o presente na doente&#41;&#59; contudo&#44; este achado semiol&#243;gico pode dever-se a eventuais fen&#243;menos de autoimunidade dirigidos&#47;locais&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Nas formas cr&#243;nicas de hipocalcemia&#44; as manifesta&#231;&#245;es incluem cataratas&#44; dismorfias dent&#225;rias e sintomas extrapiramidais por calcifica&#231;&#227;o dos g&#226;nglios basais<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A hipocalcemia grave pode acompanhar-se de diversas manifesta&#231;&#245;es cardiovasculares&#44; nas quais se incluem prolongamento do intervalo QT no eletrocardiograma&#44; vasodilata&#231;&#227;o com hipotens&#227;o arterial grave e insufici&#234;ncia card&#237;aca congestiva&#46; Estas manifesta&#231;&#245;es t&#234;m-se demonstrado revers&#237;veis com a corre&#231;&#227;o do desequil&#237;brio i&#243;nico<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">11&#44;12</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Quando grave&#44; esta altera&#231;&#227;o i&#243;nica&#44; pode comprometer a fun&#231;&#227;o mioc&#225;rdica e a consequente insufici&#234;ncia card&#237;aca congestiva&#44; habitualmente refrat&#225;ria ao tratamento convencional&#44; embora revers&#237;vel com reposi&#231;&#227;o do c&#225;lcio<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">10</span></a>&#44; tal como se verificou neste caso cl&#237;nico&#46; Salienta-se ainda que a hipocalcemia reduz a natriurese&#44; o que poder&#225; contribuir&#44; em parte&#44; para a insufici&#234;ncia card&#237;aca<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;13</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Na literatura encontram-se algumas descri&#231;&#245;es desta causa rara e revers&#237;vel de insufici&#234;ncia card&#237;aca congestiva&#44; tendo sido proposto o conceito de miocardiopatia hipocalc&#233;mica<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;10&#44;13&#8722;28</span></a>&#46; A primeira destas descri&#231;&#245;es foi efetuada em 1943 por Rose sugerindo &#171;a possibilidade de alguma rela&#231;&#227;o entre a insufici&#234;ncia paratiroideia cr&#243;nica e a les&#227;o mioc&#225;rdica&#187;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">29</span></a>&#46; Tamb&#233;m foi documentada a disfun&#231;&#227;o transit&#243;ria do ventr&#237;culo esquerdo em doentes submetidos a transfus&#245;es de sangue com citrato &#40;quelante do c&#225;lcio&#41;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Estas descri&#231;&#245;es apresentam como ponto comum casos de insufici&#234;ncia card&#237;aca em doentes com hipocalcemia grave&#44; em que se verificou uma melhoria parcial ou completa dos sintomas ap&#243;s a corre&#231;&#227;o do desequil&#237;brio i&#243;nico&#46; As etiologias da hipocalcemia foram diversas&#44; incluindo os hipoparatiroidismos iatrog&#233;nico<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;24</span></a> e autoimune<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13&#44;25</span></a> e o raquitismo<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;20&#44;28</span></a>&#46; Em alguns dos casos descritos a insufici&#234;ncia coron&#225;ria n&#227;o ter&#225; sido formalmente exclu&#237;da por coronariografia<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;22&#44;25</span></a>&#46; No entanto&#44; na maioria dos casos torna-se robusta a associa&#231;&#227;o entre as duas entidades&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No presente caso&#44; a terap&#234;utica combinada para a insufici&#234;ncia card&#237;aca e a hipocalcemia torna dif&#237;cil discriminar o efeito preciso de cada um dos tratamentos na melhoria sintom&#225;tica&#46; Todavia&#44; nalguns dos casos descritos na literatura verifica-se a aus&#234;ncia de resposta &#224; terap&#234;utica convencional&#44; tal como uma inequ&#237;voca associa&#231;&#227;o entre a introdu&#231;&#227;o ou descontinua&#231;&#227;o da corre&#231;&#227;o da calcemia e a melhoria ou o agravamento da insufici&#234;ncia card&#237;aca&#44; respetivamente<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">26&#44;27</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Embora neste caso&#44; tal como na maioria das descri&#231;&#245;es&#44; se verifique a normaliza&#231;&#227;o da fun&#231;&#227;o sist&#243;lica ventricular&#44; tal n&#227;o &#233; universal&#46; N&#227;o se encontra na literatura explica&#231;&#227;o para tal facto&#44; contudo admite-se que a exposi&#231;&#227;o do mioc&#225;rdio a hipocalcemia grave por um per&#237;odo prolongado poder&#225; causar dano estrutural&#44; como verificado em aut&#243;psia de bovinos falecidos por miocardiopatia hipocalc&#233;mica&#44; em que se descreveram focos microsc&#243;picos difusos de necrose mioc&#225;rdica<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">10&#44;30</span></a>&#46; Num doente foi efetuada biopsia mioc&#225;rdica que revelou a dilata&#231;&#227;o do ret&#237;culo sarcoplasm&#225;tico e uma variabilidade no tamanho das mitoc&#244;ndrias&#44; poss&#237;veis altera&#231;&#245;es secund&#225;rias &#224; anomalia metab&#243;lica<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Outro aspeto a discutir encontra-se relacionado com o aparecimento de sintomas agudos de hipocalcemia &#40;entre os quais insufici&#234;ncia card&#237;aca&#41; numa doente j&#225; com sinais de cronicidade do processo m&#243;rbido &#40;por exemplo&#44; calcifica&#231;&#245;es dos n&#250;cleos da base&#41;&#46; A agudiza&#231;&#227;o dos sintomas ocorre frequentemente em per&#237;odos de aumento das necessidades de c&#225;lcio&#44; como a alcalose&#44; o que se verificava nesta doente e poderia contribuir para perpetuar e ampliar a hipocalcemia<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">9</span></a>&#46; Por outro lado&#44; a rabdomi&#243;lise pode constituir a causa e a consequ&#234;ncia da hipocalcemia &#40;por altera&#231;&#227;o da atividade el&#233;trica da membrana&#44; com aumento da excitabilidade el&#233;trica da fibra muscular e consequente tremor&#41;&#44; perpetuando a altera&#231;&#227;o prim&#225;ria num ciclo vicioso<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">29&#44;31</span></a>&#46; Sendo assim&#44; torna-se evidente a import&#226;ncia da dura&#231;&#227;o da hipocalcemia em associa&#231;&#227;o &#224; sua severidade na indu&#231;&#227;o de descompensa&#231;&#227;o card&#237;aca<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">22</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Responsabilidades &#233;ticas</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prote&#231;&#227;o de pessoas e animais</span><p id="par0125" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos e&#47;ou animais&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidencialidade dos dados</span><p id="par0130" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos do seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes e que todos os pacientes inclu&#237;dos no estudo receberam informa&#231;&#245;es suficientes e deram o seu consentimento informado&#44; por escrito&#44; para participar nesse estudo&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Direito &#224; privacidade e consentimento escrito</span><p id="par0135" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47;ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia deve estar na posse deste documento&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflito de interesses</span><p id="par0140" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A associa&#231;&#227;o entre hipocalcemia e insufici&#234;ncia card&#237;aca &#233; rara&#46; Na literatura existem poucos casos descritos com esta associa&#231;&#227;o&#44; tendo-se estabelecido a entidade miocardiopatia hipocalc&#233;mica&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Relata-se o caso de uma mulher&#44; de 61 anos&#44; sem antecedentes m&#233;dicos relevantes&#46; Internada por um quadro com um m&#234;s de evolu&#231;&#227;o de dispneia de esfor&#231;o&#44; ortopneia e edema dos membros inferiores de agravamento progressivo&#46; &#192; observa&#231;&#227;o&#44; apresentava espasmos musculares difusos&#44; sem sinais de tetania latente&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Da investiga&#231;&#227;o complementar destacavam-se c&#225;lcio ionizado 0&#44;54<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;1&#44;12-1&#44;30&#41;&#44; f&#243;sforo 9&#44;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; hormona paratiroideia &#60;<span class="elsevierStyleHsp" style=""></span>2&#44;5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml e CK total<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#160;000 U&#47;l&#44; com fun&#231;&#227;o tiroideia normal&#46; O eletrocardiograma revelava um prolongamento do intervalo QT e um padr&#227;o de sobrecarga do ventr&#237;culo esquerdo e os marcadores de necrose mioc&#225;rdica eram negativos&#46; O ecocardiograma demonstrava altera&#231;&#245;es segmentares da contratilidade mioc&#225;rdica&#44; a coronariografia era normal e na TC-CE identificavam-se calcifica&#231;&#245;es dos n&#250;cleos basais e subst&#226;ncia branca&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Iniciou terap&#234;utica diur&#233;tica e de reposi&#231;&#227;o do c&#225;lcio com remiss&#227;o completa da insufici&#234;ncia card&#237;aca&#44; sem necessidade de terap&#234;utica espec&#237;fica para a mesma ap&#243;s normaliza&#231;&#227;o da calcemia&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The association between hypocalcemia and heart failure is rare&#46; There are few reported cases in the literature of this association&#44; which is termed hypocalcemic cardiomyopathy&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 61-year-old woman with no relevant medical history&#44; admitted for progressively worsening exertional dyspnea&#44; orthopnea and edema of the lower limbs for a previous month&#46; Physical examination showed diffuse muscle spasms&#44; with no signs of latent tetany&#46;Further investigation revealed ionized calcium 0&#46;54 mmol&#47;l &#40;normal 1&#46;12-1&#46;30&#41;&#44; phosphorus 9&#46;8 mg&#47;dl&#44; parathyroid hormone &#60;2&#46;5 pg&#47;ml and CK &#62;3000 U&#47;l&#44; with normal thyroid function&#46; The electrocardiogram showed long QT interval and a pattern of left ventricular overload&#44; and myocardial biomarkers were negative&#46; The echocardiogram revealed regional wall motion abnormalities&#44; coronary angiography was normal and a cranial CT scan detected calcification of basal ganglia and white matter&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">She started diuretic and calcium replacement therapy which resulted in complete clinical recovery&#44; with no need for heart failure therapy after normalization of serum calcium&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#44;8 &#40;2&#44;4-5&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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