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To share and enhance best practice management of CML, experts and interested clinicians can discuss difficult or interesting CML patient cases here. Clinicians submit a brief history of the patient and the case for discussion (no more than 200 words) by posting it in this forum ("+ NEW TOPIC" button below).

Each clinical case will be forwarded to the iCMLf expert clinical panel for a brief independent response. Consideration should be given to patient confidentiality. Details that are not critical to the case can be changed to preserve anonymity.

As a full clinical history is necessary for accurate comment, cases and comments on the Forum are only accepted from clinicians. If individual patients have a specific question we encourage them to contact their healthcare provider.

DISCLAIMER: The iCMLf does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this Forum is solely at your own risk.

TOPIC: Unsual case of CML with hypoparathyroidism

Unsual case of CML with hypoparathyroidism 1 month 3 weeks ago #1708

  • Dr Runu
  • Dr Runu's Avatar
A 32 year old female, mother of 2, was diagnosed as chronic myeloid leukemia (chronic phase) since October 2016 started on tablet Imatinib 400mg/day since then. She also has history of repeated episodes of seizures for last 7 years (controlled on tablet valproate)
Now she has stopped all treatment for last 1 month due to intolerance (vomiting, giddiness, muscle spasms).
She was hospitalized for the above complaints during which recurrent tetanic spasms of limbs were noted. On evaluation, low serum calcium (4mg/dl) , high serum phosphate (8.5mg/dl) and low serum PTH (3mg/dl) were noted. Peripheral smear shows 2% myeloblasts. No other signs of hypopituitarism / other autoimmune diseasea. Considering CML, chronic phase along with primary hypoparathyroidism, she has been restarted on tablet Imatinib 400mg/day along with oral calcium 3gm/day, Vit D 2.5ug/day, phosphate binder sevelamir and intermittent IV calcium gluconate for severe symptoms.

My queries are: what could be best course of treatment for the patient and in your experience are there any documented cases of Hypoparathyroidism in CML?
Your expert opinion is requested. Thanks and much appreciated.

Dr Runu

Unsual case of CML with hypoparathyroidism 1 month 3 weeks ago #1709

  • Mhairi Copland
  • Mhairi Copland's Avatar
Imatinib is known to cause hypocalcaemia and hypophosphataemia often in association with raised PTH levels – secondary hyperparathyroidism. I am not aware of any association between imatinib and hypoparathyroidism. Did this patient have normal calcium and phosphate levels prior to commencing imatinib?

Regarding the combination of imatinib with valproate – imatinib results in inhibition of CYP2C9 and 2C19 and will increase valproate exposure and valproate results in inhibition of CYP3A4 increasing valproate exposure. This may explain the patient’s current intolerances and it would be worth assessing drug levels and considering dose optimisation for both imatinib and valproate to improve tolerability.

In terms of the hypoparathyroidism, I would continue as you are with calcium supplements, vitamin D and phosphate binders with regular monitoring of bone metabolism.

ORIGINAL CASE:
A 32 year old female, mother of 2, was diagnosed as chronic myeloid leukemia (chronic phase) since October 2016 started on tablet Imatinib 400mg/day since then. She also has history of repeated episodes of seizures for last 7 years (controlled on tablet valproate)
Now she has stopped all treatment for last 1 month due to intolerance (vomiting, giddiness, muscle spasms).
She was hospitalized for the above complaints during which recurrent tetanic spasms of limbs were noted. On evaluation, low serum calcium (4mg/dl) , high serum phosphate (8.5mg/dl) and low serum PTH (3mg/dl) were noted. Peripheral smear shows 2% myeloblasts. No other signs of hypopituitarism / other autoimmune diseasea. Considering CML, chronic phase along with primary hypoparathyroidism, she has been restarted on tablet Imatinib 400mg/day along with oral calcium 3gm/day, Vit D 2.5ug/day, phosphate binder sevelamir and intermittent IV calcium gluconate for severe symptoms.

My queries are: what could be best course of treatment for the patient and in your experience are there any documented cases of Hypoparathyroidism in CML?
Moderators: Melissa Davis-Bishop
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