Last reviewed: 6 Nov 2021
Last updated: 09 Jul 2018



History and exam

Key diagnostic factors

  • history of thyroid, parathyroid or laryngeal surgery
  • chronic alcoholism
  • malnutrition, malabsorption, diarrhea
  • muscle twitches, spasms, cramps
  • paresthesias, numbness, tingling
  • poor memory, slowed thinking
  • Chvostek sign
  • convulsions
  • irregular heart beat, tachycardia
  • Trousseau sign

Other diagnostic factors

  • anxiety
  • dry hair, brittle nails
  • cataracts
  • history of mucocutaneous candidiasis
  • history of chronic transfusions in patients with thalassemia
  • dyspnea
  • laryngeal spasm

Risk factors

  • thyroid surgery
  • parathyroid surgery
  • hypomagnesemia
  • moderate and chronic maternal hypercalcemia (neonatal hypocalcemia)
  • autosomal dominant conditions (e.g., mutations in CASR, GATA3)
  • hereditary hemochromatosis
  • transfusional iron overload in thalassemia
  • metastatic cancer

Diagnostic investigations

1st investigations to order

  • serum calcium
  • serum albumin
  • ECG
  • plasma intact PTH
  • serum magnesium
  • serum 25-hydroxyvitamin D
  • serum phosphorus
  • serum creatinine

Investigations to consider

  • 24-hour urine calcium, creatinine
  • 24-hour magnesium, creatinine
  • liver function tests
  • arterial blood gases (ABGs)
  • serum free T4, thyrotropin
  • morning cortisol and adrenocorticotropin (ACTH) stimulation testing
  • complete blood count
  • serum iron, transferrin, ferritin
  • serum copper
  • ophthalmologic exam
  • audiology
  • renal imaging
  • gene sequencing

Emerging tests

  • autoantibodies to 21-hydroxylase or type 1 interferons

Treatment algorithm



Dolores Shoback, MD

Professor of Medicine

University of California San Francisco

Endocrine Research Unit

San Francisco VA Medical Center

San Francisco



DS worked as a consultant for SHIRE Pharmaceuticals. She has received honorarium from Neopharma, and served as an expert witness for a patient-based malpractice case. For the past 5 years, DS was a speaker for the annual patients and caregivers conference on hypoparathyroidism for the US-based Hypoparathyroidism Association, and is an unpaid member of their medical advisory board. DS has given many CME lectures on hypoparathyroidism and all kinds of calcium and bone and mineral disorders.

Quan-Yang Duh, MD

Professor of Surgery

Section of Endocrine Surgery

University of California San Francisco

San Francisco



QYD declares that he has no competing interests.


Professors Dolores Shoback and Quan-Yang Duh would like to gratefully acknowledge Professor Ronald Merrell, a previous contributor to this topic. RM declares that he has no competing interests.

Peer reviewers

Wail Malaty, MD

Adjunct Clinical Professor

Department of Family Medicine

University of North Carolina

Chapel Hill



WM declares that he has no competing interests.

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