A Case of Vitamin D Deficiency by azr57762


									                                                                 A Case of Vitamin D Deficiency
                                                     Preeti V. Rane, MD; Rosalyn W. Stewart, MD, MS—Guest Authors
                                                                  Gregory W. Rouan, MD—Column Editor

   ABSTRACT                                                                tologies all were normal. Parathyroid hormone was 938 pg/mL
    A 22-year-old man with pervasive developmental delay and               (10–69 pg/mL), 25-hydroxy vitamin D was less than 3.0 pg/mL
mental retardation presented with possible seizure activity. He            (8.9–46.7 pg/mL), and 1, 25 dihydroxy vitamin D was 8.3
had a history of muscle cramping and pain with associated                  pg/mL (25.1–66.1 pg/mL). A computed tomography of the head
increased emotional irritability. A thorough activity and dietary          without contrast was normal.
history helped to elucidate the cause of his ailments.                         This patient was diagnosed with hypocalcemia secondary to
                                                                           vitamin D deficiency. On further questioning the patient’s moth-
                                                                           er disclosed that her son had not left his home for the past 2 to 3
                                                                           months. He had previously participated in a day program for
 CASE PRESENTATION                                                         children with disabilities, which he had attended 3 to 4 times per
      A 22-year-old African American man with a pervasive devel-           week. However, during the past several months he had not gone
 opmental delay and mental retardation presented with possible             given his increased irritability. A thorough dietary history revealed
 seizure activity. His mother reported that he suddenly began              a limited diet consisting of Spaghettios, chicken tenders, and
 screaming that afternoon while he was in bed; his arms extended           french fries. His diet lacked vitamin D rich foods (dairy products,
 in front of him. His mother had attempted to stand him up, but            eggs, and fish) and vitamin D-fortified foods (milk and cereals).1
 he proceeded to fall to the ground breathing heavily. The moth-           Both the limited outdoor activity and restricted diet were likely
 er then called 911 who transported the patient to the emergency           causal for this patient’s vitamin D deficiency.2
 department for further evaluation. The young man remained                     The patient was begun on oral vitamin D replacement 500
 unresponsive to his mother’s commands throughout this episode,            000 units daily and intravenous calcium replacement (1 g intra-
 which lasted less than 30 minutes. There was no bowel or urinary          venous daily for 3 days). He had significant improvement in his
 incontinence. The patient was admitted to a general medicine              symptoms following his first intravenous calcium dose and, by the
 inpatient service for further workup.                                     time of discharge after 4 days of observation, he was more inter-
                                                                           active and appeared more contented than he had been in many
 MEDICAL HISTORY                                                           months prior to admission. He did not have any more seizure-like
     In general, the patient was nonverbal, and could not perform          episodes of fits after the first intravenous calcium dose.
 his activities of daily living with the exception of feeding himself.
 In addition, he had been taking ibuprofen and oxycodone for the           DISCUSSION
 past 3 years for generalized pain and emotional irritability of               Severe deficiency of vitamin D is manifested as rickets in
 unclear etiology. He had become increasingly restless with inter-         children and osteomalacia in adults. In infants, nutritional
 mittent episodes of fist banging during the past several years.           rickets occurs at ages 5 to 25 months with the median age of
 Both his mother and doctors attributed this behavior to pain.             diagnosis 15.5 months.3 The risk for vitamin D deficiency
                                                                           increases with breast-feeding beyond 6 months without supple-
 PHYSICAL EXAMINATION/LABORATORY ANALYSIS                                  mentation. A 2002 study of young health adults living in Boston,
     On physical examination, the patient’s blood pressure was             Massachusetts, found that 36% of adults aged 18 to 20 years had
 125/76 mm Hg, pulse 90 bpm, oral temperature 97ºF, and room               vitamin D deficiency at the end of winter.4 Another study that
 air pulse oximetry 99%. He appeared restless and was lying in a           evaluated healthy adults from Minneapolis aged 10 to 65 years
 fetal position. His head was normocephalic. Pupils were equally           and who had persistent, nonspecific musculoskeletal pain found
 round and reactive to light. The mucous membranes were moist.             that 93% had deficient levels of vitamin D.5 The prevalence of
 Chest, heart, and abdominal examinations were normal. No                  vitamin D deficiency is estimated to be between 25% and 54%
 peripheral edema was noted and movement of all extremities was            in patients older than 65 years.6
 observed. There were no bone or joint deformities.                            Vitamin D deficiency may be secondary to multiple etiolo-
     The serum chemistries were all within normal limits, with the         gies, including decreased dietary intake or absorption, reduced
 exception of a total calcium of 4.8 mg/dL (8.6–10 mg/dL) and a            exposure to the sun, increased hepatic catabolism, decreased
 serum phosphorus of 2.5 mg/dL (2.8–4.6 mg/dL). The albumin                endogenous synthesis, or end-organ resistance (Table).6,7 Risk fac-
 was 3.8 g/dL (3.5–5.2 g/dL). His liver function tests and hema-           tors for vitamin D deficiency include extreme latitudes, advanced
                                                                           age, institutionalization (both nursing home, state institutions,
Dr Rane is a resident physician, Department of Internal Medicine,          and prison system), and disabilities such as pervasive develop-
University of Maryland Medical School, Baltimore, Maryland.                mental delay, mental retardation, or other disabilities. African
Dr Stewart is Assistant Professor of Medicine, Department of Internal      Americans and persons with darker complexions also are prone to
Medicine, Division of General Medicine, Johns Hopkins University,          vitamin D deficiency because higher melanin content in the skin
Baltimore, Maryland.
Dr Rouan is Richard W. and Sue Vilter Professor of Clinical Medicine and   is associated with lower cutaneous synthesis of vitamin D.6
Associate Chairman of Education, Department of Internal Medicine, School   Diseases including renal failure and liver failure can cause sub-
of Medicine, University of Cincinnati, Cincinnati, Ohio.                   stantial reductions in serum vitamin D-binding protein, which

Johns Hopkins Advanced Studies in Medicine                                                                                                  371
                                                                                                                                                     CLINICAL VIGNETTE

lowers the serum 25-hydroxy vitamin D concentration. Obesity                  There are currently no national guidelines or recommendations
also contributes to deficiency because vitamin D accumulates in fat       for routine screening for vitamin D deficiency or for vitamin D
stores and cannot circulate in the body.8 In addition, malabsorption      supplementation. Patients with calcidiol levels less than 8 pg/mL
of ingested fats causes loss of fat-soluble vitamins, including vitamin   should be given 50 000 IU of ergocalciferol daily until calcidiol lev-
D, and can contribute to deficiency. This can occur in patients with      els are greater than 20 pg/mL (usually 1–3 weeks).9,14 If dietary
chronic vomiting and diarrhea, celiac disease, inflammatory bowel         changes have been made, patients can be maintained on the above
disease, and individuals who are post bariatric surgery. Finally, med-    recommended daily intakes; however, if a vitamin D-deficient diet
ications such as rifampin, phenytoin, and carbamazepine impair            persists, then 1500 to 5000 IU of vitamin D2 daily or 50 000 IU
vitamin D activation or accelerate clearance and contribute to vita-      per week may be required.9
min D deficiency.6,8,9
     Vitamin D has the net effect of increasing serum calcium and         CONCLUSIONS
phosphate levels and achieves this by increasing intestinal calcium            This patient illustrates a case of severe vitamin D deficiency
and phosphate absorption. Vitamin D deficiency results in reduced         with hypocalcemia. The event that brought him to the hospital was
serum calcium, which triggers secretion of parathyroid hormone            likely tetanic spasms. His long-standing pain of unknown etiology
and increases the release of calcium and phosphorus from bone in          was likely secondary to muscle cramps and bone pain from the
an attempt to maintain normal serum calcium levels.10,11                  hypocalcemia. Once his serum calcium had been corrected he no
     Patients with vitamin D deficiency may present with symptoms         longer required pain medications and has been doing well since.
of hypocalcemia.12,13 This includes neuromuscular irritability, con-           In recent years, there has been a focus placed on the need for
vulsions, tetany, and paresthesias. Severe deficiency of vitamin D        adequate calcium and vitamin D intake in all adults, given the
may manifest itself as rickets in children and osteomalacia in adults.    prevalence of osteoporosis.1 However, as evidenced by this case, it
Osteomalacic myopathy is a manifestation of vitamin D deficiency          is equally as important to target patients who are at high risk for
that presents as nonspecific diffuse muscle pain, deep bone pain,         dietary or environmental causes of vitamin D deficiency. An
arthralgias, and paresthesias.6                                           understanding of the symptoms of hypocalcemia, including
     In patients at risk for vitamin D deficiency, preventative mea-      tetany, muscle cramping, or pain, can avoid incorrect diagnosis
sures, such as dietary supplements or an outdoor activity pro-            such as polymyalgia, fibromyalgia, nonspecific rheumatic disease,
gram, may be taken if necessary. The current recommended daily            or even occult malignancy. All patients, especially those at high
intake of vitamin D3 is 200 IU for children, adolescents, and             risk, should have both an activity and diet history, and any patient
adults up to the age of 50 years, 400 IU for adults aged 51 to 70         with a clinical suspicion for vitamin D deficiency should be
years, and 500 IU for those aged 71 years and older.8 Calcidiol           screened for deficiency.
(25-hydroxy vitamin D) serum levels can be used as a clinical
measure of vitamin D stores.                                              References
                                                                          1.    Utiger R. The need for more vitamin D. N Engl J Med. 1998;838:828-829.
                                                                                Available at: http://NEJM.org. Accessed August 30, 2004.
                                                                          2.    Up to Date. Clinical manifestations of hypocalcemia. Available at:
                                                                                h t t p : / / w w w. u t d o l . c o m / u t d / c o n t e n t / t o p i c . d o ? t o p i c K e y = m i n -
                                                                                metab/18931&type=A&selectedTitle=1~85. Accessed August 23, 2004.
Table. Causes of Vitamin D Deficiency                                     3.    Rajakumar K. Vitamin D, cod-liver oil, sunlight, and rickets: a historical
                                                                                perspective. Pediatrics. 2003;112:132-135.
Deficient intake or absorption                                            4.    Tangpricha V, Pearce E, Chen TC, et al. Vitamin D insufficiency among
                                                                                free-living healthy young adults. Am J Med. 2002;112:659-662.
  • Dietary deficiency                                                    5.    Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in
  • Insufficient sunlight exposure                                              patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc.
  • Malabsorption                                                               2003;78:1463-1470.
      – Inflammatory bowel diseases                                       6.    Mascarenhas R, Mobarhan S. Brief critical review, hypovitaminosis D-
      – Celiac diseases                                                         induced pain. Nutr Rev. 2004;63:354-359.
      – Gastrectomy/bariatric surgery                                     7.    Up To Date. Causes of vitamin D deficiency and resistance. Available at:
      – Pancreatic insufficiency                                                http://www.utdol.com/utd/content/topic.do?topicKey=minmetab/20450&type
                                                                                =A&selectedTitle=14~123. Accessed August 13, 2004.
Defective 25-hydroxylation                                                8.    Meyer C. Scientists probe role of vitamin D deficiency a significant problem,
  • Hepatic diseases                                                            experts say. JAMA. 2004;292:1416-1418.
      – Cirrhosis                                                         9.    Lyman D. Undiagnosed vitamin D deficiency in the hospitalized patient.
      – Alcoholic liver disease                                                 Am Fam Physician. 2005;71:299-304.
  • Medications                                                           10.   Fauci A, Braunwald E, Isselbacher K, et al. Harrison’s Principles of Internal
      – Anticonvulsants                                                         Medicine. 14th ed. New York, NY: McGraw Hill; 1998.
      – Rifampin                                                          11.   Up to Date. Metabolism of vitamin D. Available at: http://www.utdol.
Defective 1,25-hydroxylation                                                    =2~123. Accessed October 16, 2004.
  • Hypoparathyroidism                                                    12.   Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D
  • Renal failure                                                               deficiency. Arch Dis Child. 2004;89:781-784.
Decreased serum vitamin D-binding protein                                 13.   Allgrove J. Is nutritional rickets returning? Arch Dis Child. 2004;89:699-670.
                                                                          14.   Up To Date. Vitamin D therapy in osteoporosis. Available at:
  • Renal failure                                                               h t t p : / / w w w. u t d o l . c o m / u t d / c o n t e n t / t o p i c . d o ? t o p i c K e y = m i n -
  • Nephrotic syndrome                                                          metab/11247&type=A&selectedTitle=3~123. Accessed March 2, 2005.

372                                                                                                                                 Vol. 6, No. 8           I   September 2006

To top