Gitelman syndrome and ectopic calcification in the retina and joints

Abstract

Gitelman syndrome is a rare inherited renal tubular disorder with features that resemble thiazide use, including a hypokalemic metabolic alkalosis, hypomagnesemia, hypocalciuria and a low or normal blood pressure, hyperreninemia and hyperaldosteronism. Treatment is primarily correction of the potassium and magnesium levels. The diagnosis is confirmed with genetic testing but Gitelman syndrome is often not suspected. However, the association with ectopic calcification in the retina, blood vessels and chondrocalcinosis in the joints is a useful pointer to this diagnosis. Bilateral symmetrical whitish deposits of calcium pyrophosphate are visible superotemporally on ophthalmoscopy and retinal photography but are actually located beneath the retina in the sclerochoroid. Optical coherence tomography is even more sensitive for their detection. These deposits increase in size with time, but the rate of progression slows with long-term correction of the hypomagnesemia. Calcification may be complicated by atrophy of the overlying retina and visual loss. The deposits often correlate with ectopic calcification in the aorta and coronary and cerebral vessels. Chondrocalcinosis occurs in the large joints such as the knees. Ectopic calcification in Gitelman syndrome indicates the need for more aggressive management of Mg levels. Calcification is much less common in Bartter syndrome, which itself is rarer and associated less often with hypomagnesemia.

Keywords: Bartter syndrome; Gitelman syndrome; chondrocalcinosis; hypertension.

FIGURE 1

Ectopic calcification in a 74-year-old woman with Gitelman syndrome and poor Mg control. (A and B) Subepithelial opacities of the cornea (arrows). (C and D) Yellow deposits due to sclerochoroidal calcification in the superior temporal retina (arrow). (E and F) Enlarged deposits 9 years later (arrow). (G) Central retinal vein occlusion with dilated tortuous venules and hemorrhages (arrow) possibly due to late-onset hypertension. (H and I) OCT demonstrating choroidal deposits with ‘mountain-like’ features. (J) Ultrasound of the eye demonstrating a choroidal mass (arrow). (K) Right knee radiograph with calcified cartilage consistent with chondrocalcinosis (arrow).

FIGURE 1

Ectopic calcification in a 74-year-old woman with Gitelman syndrome and poor Mg control. (A and B) Subepithelial opacities of the cornea (arrows). (C and D) Yellow deposits due to sclerochoroidal calcification in the superior temporal retina (arrow). (E and F) Enlarged deposits 9 years later (arrow). (G) Central retinal vein occlusion with dilated tortuous venules and hemorrhages (arrow) possibly due to late-onset hypertension. (H and I) OCT demonstrating choroidal deposits with ‘mountain-like’ features. (J) Ultrasound of the eye demonstrating a choroidal mass (arrow). (K) Right knee radiograph with calcified cartilage consistent with chondrocalcinosis (arrow).