A case report: Magnesium intoxication occurring in the process of total serum magnesium decrease

Magnesium intoxication is a result of excessively high serum magnesium levels, which are generally represented by a patient's total serum magnesium concentration. This is the first case report in PubMed in which a female patient showed no signs of magnesium intoxication when her total serum magnesium concentration was 4.34 mg/dL, but showed signs of magnesium intoxication (i.e. absent-patellar reflex) when the concentration was 3.66 mg/dL. We concluded that the serum magnesium level cannot be represented by the total serum magnesium concentration to a full extent; a lower total serum magnesium concentration may still lead to magnesium intoxication.