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Serum iCa had declined from 4.38 to 3.29?mg/dl and serum 25-hydroxyvitamin D level was found to be low at 17?ng/ml. He was transferred to the intensive care unit and placed on a continuous intravenous calcium gluconate infusion. In the evaluation of the refractory hypocalcaemia, it was noted that Veliparib the significant decline in serum calcium concentration coincided with an increased rate of output of chyle originating from the thoracic duct injury (see Fig. 1). At that time on post-operative day 5, serum Ca was at its lowest level and the rate of the chyle output was at its maximum at 115?cc over 24 hours. Biochemical analysis of the chyle revealed a total calcium concentration of 5.3?mg/dl. Circulating 25-hydroxyvitamin D and its active 1, 25-dihydroxyvitamin D were not measured, but are typically present in chyle. Figure 1 Association between ionized calcium concentration and the rate of chyle leak. Treatment Over the following five days, doses of calcium carbonate were increased to 4 g, calcitriol to 4 ��g, and vitamin D2 to 50?000 IU daily. The chyle leak was managed by initiating both a medium chain fatty acid diet, which contained a low fat content, and subcutaneous octreotide 100 microgram three times daily for 10 days. Outcome and follow-up Subsequently the chyle output decreased to DDR1 of i.v. calcium and only on oral supplementation. Serum iCa level gradually improved to a range from 3.7 to 4.2 mg/dl over the ensuing 3 days, and tetany symptoms resolved. Discussion The main cause of hypocalcemia in this patient was post-surgical hypoparathyroidism; however, our patient's abrupt worsening of Temozolomide hypocalcemia may have been exacerbated by the calcium and vitamin D losses from a leak of chyle from an injured thoracic duct. Notably, as the rate of chyle output declined with nutrition modification and medical therapy, serum iCa improved and supplementation requirements declined. Chyle is an odorless, alkaline fluid. Approximately 2�C4?l of chyle are produced each day. Approximately 70% of chyle is absorbed dietary fat, mainly in the form of triglycerides. Chyle has an electrolyte concentration similar to that of plasma (3). Leaks of chyle fluid commonly result in nutritional deficiencies due to the loss of calories (200/l), protein, and fat-soluble vitamins. Metabolic complications including hypocalcemia may also occur due to the loss of fluid and electrolytes (4). Treatment options for a chyle leak include drainage, conservative therapy with nutrition intervention with fat-free oral diet, or parenteral nutrition without oral intake, pharmacological treatment (primarily octreotide), and finally direct surgical repair.