A research article on dementia in old age Zimbabweans.Dementia is under-diagnosed in routine clinical practice in the developing world. Symptoms are often attributed to normal ageing, even though they may be a result of underlying medical conditions. We report a case of a patient with extensive cerebral calcification due to hypoparathyroidism who was being managed for dementia. While cases of extensive calcification in parathyroid hormone disorders have been reported sporadically in the literature over the years, the current case highlights the potential diagnostic pitfalls when patients present with dementia

Katsidzira, L.

Machiridza, T.

Ndlovu, A.

Central African Journal of Medicine

English

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Vol. 56, Nos. 5/8 CONTENTS
ORIGINAL ARTICLES
<
Bilateral HIV related ocular surface squamous R Masanganise, A Mukome, J Dari, R Makunike-
neoplasia: a paradigm shift?............................................  Mutasa.................................................................................... 23
'
Use of cotrimoxazole prophylaxis in HIV infected in S Khoza, V Mkudu, J Mthethwa, R Bulaya-Tembo, CFB
-patients at a referral hospital........................................... Nhachi.....................................................................................26
Annual distribution of births and births outcomes at
Harare Maternity Hospital, Zimbabwe............................ S Feresu................................................................................... 30
A potentially treatable cause of dementia......................  PL Katsidzira, T Machiridza, A Ndlovu..............................41
CASE REPORTS
Post operative fatal hypothermia in hydranencephaly 
with pre-operative hypothermia and a 7th nerve palsy:
A case report......................................................................  A Musara, KKN Kalangu..................................................... 44
May/August 2010
NOTES AND NEWS Central African Journal o f Medicine. .48
A potentially treatable cause of dementia
CASE REPORTS___________________
Abstract
L KATSIDZIRA, T MACHIRIDZA, A NDLOVU
Idiopathic hypoparathyroidism is an uncomm on medical condition, which may present with dementia. This may 
be misdiagnosed as 'senile dementia' in elderly patients. We report such a case, made more remarkable by 
associated extensive cerebral calcification and we review the background literature.
Cent Afr J  Med 2010;56(5/8) 41-44
Department o f Medicine
University of Zimbabwe College of Health Sciences 
P O Box A178 
Avondale, Harare 
Zimbabwe
Corresponding to:
Dr Leolin Katsidzira 
Department o f Medicine
University o f Zimbabwe College of Health Sciences
P O Box A178, Avondale, Harare
Zimbabwe
E-mail: lkatsidzira@hotmail. com
Cent Afr J  Med 2010;56(5/8) 41
Dementia is under-diagnosed in routine clinical 
practice in the developing world. Symptoms are often 
attributed to normal ageing, even though they may be a 
result o f underlying medical conditions. We report a 
case of a patient with extensive cerebral calcification 
due to hypoparathyroidism who was being managed 
for dementia. While cases o f extensive calcification in 
parathyroid hormone disorders have been reported 
sporadically in the literature over the years, the current 
case highlights the potential diagnostic pitfalls when 
patients present with dementia.15
C ase  R e p o rt
A 77 year old woman presented to a referral hospital in 
Harare, Zimbabwe, with a 4 month history of 
progressive memory impairment and confusion. She 
had developed auditory and visual hallucinations in the 
2 months preceding presentation. Her mental state had 
rapidly deteriorated over this period; she would 
occasionally forget her children and had developed 
paranoia. She had not been communicating in the 3 
days prior to presentation. She was being managed for 
'senile dementia' and was on amitrypline 25mg and 
haloperidol 5mg daily. She had no history of 
hypertension, diabetes mellitus or previous strokes and 
she did not smoke or use alcohol. On examination she 
was afebrile and her blood pressure was 110/70mmHg. 
She had a Glasgow coma scale o f 10 but there were no 
focal signs. There were coarse crepitations over the 
right lung base.
The results of investigations done were as follows; 
white cell count 14.88x 103/pL (neutrophils 83.6%, 
lymphocytes 9.3%, monocytes 6.9%, eosinophils
0.1%, and basophils 0.1%), haemoglobin 12.4g/dl, 
platelets 279 x 103/pL, sodium 143mmol/L, potassium 
3.4mmol/L, urea 13.8mmol/L, creatinine 108mmol/L 
and glucose 8.3 mmol/L. She was commenced on 
intravenous fluids and antibiotics for the pneumonia. 
Computerised tomography scan of the brain (Fig I) 
demonstrated extensive symmetrical calcification 
involving the dentate nuclei in the cerebellum, the 
centrum semi ovale, basal ganglia and peri-ventricular 
a re a s . S u b se q u e n t in v e s t ig a t io n s  re v e a le d  
hypocalcemia and hyperphosphataemia [calcium 1.04 
m mol/L(2.1-2.55), albumin 26g/l and phosphate 
2.42mmol/L]. Intravenous calcium gluconate was 
commenced but she continued to deteriorate, and died 
11 days after admission. The final diagnosis was 
hypoparathyroidism with cerebral calcification and 
pneumonia.
Introduction Figure la: CT scan demonstrating bilateral 
symmetrical calcification o f the dentate nuclei in the 
celebellum.
Figure lb: Extensive symmetrical basal ganglia and 
peri-ventricular calcification.
Figure lc: Peri-ventricular calcification extending to 
involve the centrum semi-ovale bilaterally.
Cent Afr JM ed  2010;56(5/8) 42
Cerebral calcification is associated with a diverse 
group of conditions including neurocysticercosis, 
toxoplasmosis, healed tuberculous granulomas, 
cryptococcom as, haem ochrom atosis, tuberous 
sclerosis, myotonic muscular dystrophy, tumours, 
aneurysms and Fahr's disease.6 However, symmetrical 
calcification involving the dentate nuclei and the 
corona radiata is considered pathognom ic o f 
hypoparathyroidism or pseudohypoparathyroidism2. 
The current case serves not only as a reminder o f this 
little known fact, but more importantly, amply 
illustrates the dictum that primary dementia should be a 
diagnosis o f exclusion.
Hypocalcaemia, which is usually caused by 
hypoparathyroidism is one o f the many conditions 
which can present with dementia.3'7'8 The dementia is 
characterised by “poor concentration, impaired 
memory, disorientation and apathy”9. Dementia in 
elderly patients can also be due to nutritional 
deficiencies (e.g vitamin B12 deficiency, pellagra), 
thyroid disease, chronic subdural haemorrhage, normal 
pressure hydrocephalus, HIV infection or intracranial 
tumours among other causes. More commonly, it is a 
result o f the primary dementia syndromes such as 
alzheimer's disease, vascular dementia, Lewy body 
dementia and frontotemporal dementia. An attempt 
should be made to differentiate them in clinical practice 
as management strategies may differ.
The proper evaluation of patients presenting with 
dementia includes meticulous history taking, including 
collateral history from close family members and a 
comprehensive physical and mental state examination. 
Whenever possible, the following investigations 
should be performed; full blood count, erythrocyte 
sedimentation rate, urea and electrolytes and thyroid 
function tests.10 A lumbar puncture should be carried 
out if  clinically appropriate. Computed tomography 
scan of the brain may be considered, especially when 
the history and examination suggest secondary causes 
such as a chronic subdural haemorrhage or intra-cranial 
tumours. This is often unavailable or costly in resource 
limited settings and history taking becomes even more 
crucial, as it allows investigations to be targeted.
The unavailability o f more extensive investigations 
was apparent in the management o f our patient, as it 
was not possible to perform a parathyroid hormone 
assay. However, the presence of hypocalcemia and 
hyperphosphataemia with normal renal function, and 
the pathognomonic CT findings virtually confirms the 
diagnosis. Historically, the criteria for diagnosing 
idiopathic hypoparathyroidism has been a low serum 
calcium in the presence o f high serum inorganic 
phosphorus level and normal renal function.11 The 
major differential diagnosis of the radiological findings 
in our patient would be bilateral striopallidodentate 
calcinosis, commonly known as Fahr's disease12. 
However, this rare familial disease is not associated 
with calcium and phosphate abnormalities despite
Discussion causing extensive cerebral calcification.
T h e r e  a r e  t w o  w a y s  t h r o u g h  w h i c h  
hypoparathyroidism give rise to dementia. Firstly, 
hypocalcaemia may present with symptoms of 
dementia, which resolve after correction.1,9 Less 
recognised, is the fact that chronic hypoparathyroidism 
is associated with long term cognitive decline, even if it 
is well controlled.13 This is often associated with the 
presence o f cerebral calcification. Interestingly, motor 
and movement disorders in hypoparathyroidism are 
also associated with cerebral calcification. This 
s u g g e s t s  t h a t  c e r e b r a l  c a l c i f i c a t i o n  in 
hypoparathyroidism plays a role in the pathogenesis o f 
the various neurological abnormalities seen in the 
condition.7,13
It was not possible to distinguish between 
hypoparathyroidism and pseudohypoparathyroidism 
in our patient. Curiously, calcification is more common 
in the rarer pseudohypoparathyroidism.5 However, 
pseudohypoparathyroidism has other associated 
pheno typ ic  fea tu re s  such as short  s ta ture,  
brachydactyly, and a round face apart from heterotopic 
calcification.14 Our patient certainly had idiopathic 
hypoparathyroidism, a condition which is often 
diagnosed late in Africa.15
Conclusion
It is crucial to rule out secondary causes o f dementia in 
elderly patients presenting with cognitive impairment 
because correction some o f these factors, such as 
hypocalcemia can arrest or even reverse the symptoms.
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A potentially treatable cause of dementia

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