Severe Hypertriglyceridemia Without Pancreatitis Causing Total Pseudohypocalcemia With True Ionized Symptomatic Hypocalcemia: A Diagnostic Pitfall

Severe hypertriglyceridemia (HTG) can interfere with laboratory assays. HTG-induced pancreatitis usually presents with hypocalcemia, but the effect of severe HTG, with no associated pancreatitis, on calcium levels is not well described. We present a 25-year-old male with severe HTG and diabetes who presented with generalized weakness, nausea, and vomiting. His labs revealed a severely elevated triglyceride level, as well as a critically low total calcium of 2.8 mg/dL, but only mildly reduced ionized calcium (1.10 mmol/L), with no evidence of laboratory or imaging findings of pancreatitis. Hypocalcemia signs were positive on physical examination. Treatment for HTG led to rapid normalization of total calcium levels, while intravenous calcium gluconate normalized ionized calcium and resulted in symptom resolution. This case shows that severe HTG can cause significant total pseudohypocalcemia alongside mild true ionized hypocalcemia, highlighting the importance of monitoring ionized calcium in this setting.