Hypomagnesemia

 

Original Editors -Shawn Abraham & Sean Joyce- Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Shawn Abraham, Sean Joyce, Lucinda hampton, Kim Jackson, Elaine Lonnemann, Selena Horner, 127.0.0.1 and WikiSysop  

Definition/Description

Magnesium is a principal cation in the intracellular fluid that is an essential part of many enzyme systems associated with energy metabolism. Hypomagnesemia is an electrolyte imbalance with inadequate levels of magnesium in the bloodstream. Serum magnesium levels are rarely deficient in healthy individuals because magnesium is abundant in foods and water and its excretion through urine is limited by the kidneys. However, certain medical conditions and medications can cause excessive loss of magnesium resulting in deficiency.

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Prevalence

Incidence of hypomagnesemia in the United States general population has been estimated to be less than 2%. Additionally, studies have estimated that up to 75% of Americans do not meet the recommended dietary allowance of magnesium. The risk of becoming magnesium deficient in the United States is listed below.

• 2% in the general population
• 10-20% in hospitalized patients
• 50-60% in intensive care unit (ICU) patients
  
• 30-80% in persons with alcoholism
• 25% in outpatients with diabetes

Characteristics/Clinical Presentation

Electrolyte abnormalities

Hypokalemia
Hypocalcemia

Neuromuscular

Hyperirritability
Carpopedal spasm
Tetany
Muscle cramps
Muscle fasciculations
Chvostek's sign (fascial muscle spasms induced by tapping the branches of the facial nerve)

Neurologic

Vertigo
Nystagmus
Aphasia
Hemiparesis
Depression
Delirium
Choreoathetosis

Cardiovascular

Ventricular arrhythmias
Torsade de points
Superventricular tachycardia
Enhanced sensitivity to digoxin
Vasomotor changes
Occasionally Hypertension

Central Nervous System

confusion
delusions
hallucinations
seizures
Abnormal eye movements

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Associated Co-morbidities

Gastrointestinal diseases

Type II Diabetes

Alcoholism

Older adults

Hypertension

Cardiovascular Disease

Osteoporosis

Migraine Headaches

Medications

Magnesium is commonly found in plant and animal foods as well as in beverages. Green leafy vegetables such as spinach, legumes, nuts, seeds, and whole grains, are sources high in magnesium. Also, foods containing dietary fiber typically provide high levels of magnesium. Tap, mineral, and bottled waters can also contain magnesium, but the amount of magnesium in water varies by source and brand.

Magnesium supplements are available in a variety of forms, including magnesium oxide, citrate, and chloride. Small studies have found that magnesium in the form of aspartate, citrate, lactate, and chloride are absorbed more completely than magnesium oxide and magnesium sulfate.

Diagnostic Tests/Lab Tests/Lab Values

The average adult holds approximately 25 g magnesium. 50% to 60% is found in the bones and most of the rest is found in soft tissue, the remaining less than 1% of magnesium is found in blood serum. Normal serum magnesium levels fall between 0.75 and 0.95 mmol/L. Hypomagnesemia is characterized as serum levels falling below 0.75 mmol/L.

Etiology/Causes

• Alcoholism
• Burns that affect a large area of the body
• Chronic diarrhea
• Excessive urination (polyuria), such as in uncontrolled diabetes and during recovery from acute kidney failure
• High blood calcium level (hypercalcemia)
• Hyperaldosteronism
• Malabsorption syndromes, such as celiac disease and inflammatory bowel disease
• Malnutrition
• Medicines including amphotericin, cisplatin, cyclosporine, diuretics, proton pump inhibitors, and aminoglycoside antibiotics
• Sweating
• Diuretics
• Antiarrhythmic medications
• Antifungal medications 
• Antiviral medications 

Systemic Involvement

Hypomagnesemia has a systemic link to other electrolyte deficiencies, especially hypokalemia and hypocalcemia.

Hypokalemia has been found to occur in 40-60% of cases of hypomagnesemia cases. This is related to underlying disorders that cause magnesium and potassium losses like diuretic therapy and diarrhea. The mechanism for hypomagnesemia-induced hypokalemia relates to the intrinsic biophysical properties of renal outer medullary potassium channels mediating potassium secretion in the thick ascending limb and the distal nephron.

The mechanism of hypocalcemia is multifactorial. Parathyroid gland function is abnormal, largely because of impaired release of parathyroid hormone. Impaired magnesium-dependent adenyl cyclase generation of cyclic adenosine monophosphate mediates the decreased release of parathyroid hormone. Skeletal resistance to this hormone in magnesium deficiency has also been implicated. Hypomagnesemia additionally changes the heteroionic exchange of calcium and magnesium at the bone surface, causing increased bone release of magnesium ions in exchange for an increased skeletal uptake of calcium from the serum.

Medical Management (current best evidence)

• Fluids given through a vein (IV)
• Magnesium by mouth or through a vein
• Medicines to relieve symptoms

Physical Therapy Management (current best evidence)

There are no direct physical therapy interventions for hypomagnesemia. Patient will be referred to physical therapy for treatment of impairments that may be a cause of hypomagnesemia such as decline in muscle strength, fatigue, or abnormal eye movements. (See Clinical Presentation)

Physical therapists can take a team approach with medical management through patient education on:

• Foods high in magnesium
• Importance of following medical recommendations for magnesium intake
  
  

Differential Diagnosis

Hypomagnesemia can be masked as other electrolyte imbalances. Therefore, obtain magnesium levels with other electrolytes (eg, potassium, calcium, phosphorus) when ordering laboratory tests.

• hypocalcemia
• hypokalemia

Case Reports/ Case Studies

1. Bircan I, Turkkahraman D, Dursun O, Karaguzel G. Successful management of primary hypomagnesaemia with high-dose oral magnesium citrate: A case report. Acta Paediatrica [serial on the Internet]. (2006, Dec), [cited April 7, 2016]; 95(12): 1697-1699. Available from: Academic Search Complete.

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2. Daskalakis G, Marinopoulos S, Mousiolis A, Mesogitis S, Papantoniou N, Antsaklis A. Gitelman syndrome-associated severe hypokalemia and hypomagnesemia: case report and review of the literature. Journal Of Maternal-Fetal & Neonatal Medicine [serial on the Internet]. (2010, Nov), [cited April 7, 2016]; 23(11): 1301-1304 4p. Available from: CINAHL.

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3. Hypomagnesaemia in an elderly patient: case report. Reactions Weekly [serial on the Internet]. (2011, Aug 27), [cited April 7, 2016]; (1366): 23-24. Available from: Academic Search Complete.

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4. Wang A, Sharma S, Kim P, Mrejen-Shakin K. Hypomagnesemia in the intensive care unit: Choosing your gastrointestinal prophylaxis, a case report and review of the literature. Indian Journal Of Critical Care Medicine [serial on the Internet]. (2014, July), [cited April 7, 2016]; 18(7): 456-460. Available from: Academic Search Complete.

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Resources

ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/ - Magnesium Fact Sheet for Health Professionals (NIH)

- Informational video on Hypomagnesemia