Refractory hypocalcaemia-induced laryngeal spasm requiring emergency intubation in a malnourished young woman: overcoming diagnostic and therapeutic barriers in resource-limited settings

Hypocalcaemia-induced laryngospasm is a rare but life-threatening cause of upper airway obstruction. Management is particularly challenging in resource-limited settings due to delayed laboratory results, limited monitoring, and unavailability of preferred medications. A 20-year-old previously healthy woman presented with severe stridor, respiratory distress, and carpopedal spasm. Laboratory findings (obtained after initial treatment) revealed ionized calcium 0.9 mmol/L (reference range: 1.12–1.32 mmol/L), magnesium 1.6 mg/dL (reference range: 1.7–2.3 mg/dL), and severe vitamin D deficiency (25-hydroxyvitamin D 11.83 ng/mL; severe deficiency < 10–12 ng/mL). Despite aggressive intravenous calcium gluconate boluses (2 g × 4 additional doses after initial), continuous infusion (up to 2 mg/kg/h), and magnesium replacement, laryngospasm progressed to complete airway obstruction with desaturation to 70%. Emergency rapid sequence intubation was performed with ketamine 100 mg (2.5 mg/kg) and vecuronium 4 mg. Because calcitriol was unavailable, intramuscular cholecalciferol 50,000 IU was administered as off-label loading. The patient was extubated after 72 hours and discharged after 8 days with normalized levels on continued cholecalciferol therapy. Favourable outcomes can be achieved in resource-limited emergency departments through clinically guided aggressive therapy, timely airway intervention, and pragmatic use of available long-acting vitamin D when preferred agents are inaccessible. This underscores the value of adaptable strategies in low-resource settings.