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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 26  |  Issue : 1  |  Page : 66-68

Vitamin D toxicity presenting as quadriparesis


Department of General Medicine, Grant Government Medical College and JJ Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission07-Apr-2020
Date of Acceptance13-Jan-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Kanishka Kumar
1104b Olympia Towers Byculla West, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_35_20

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  Abstract 

Vitamin D usage is becoming more and more common in the world with newer roles ascribed to it. The side effects of inadvertent overdose have been documented. Here, we present a case of Vitamin D toxicity who presented uniquely with quadriparesis.

Keywords: Hypercalcemia, Vitamin D overdose, Vitamin D toxicity, quadriparesis


How to cite this article:
Patil P, Kumar K, Aghrahari N, Jayaraman H. Vitamin D toxicity presenting as quadriparesis. J Mahatma Gandhi Inst Med Sci 2021;26:66-8

How to cite this URL:
Patil P, Kumar K, Aghrahari N, Jayaraman H. Vitamin D toxicity presenting as quadriparesis. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2021 Nov 28];26:66-8. Available from: https://www.jmgims.co.in/text.asp?2021/26/1/66/319845


  Introduction Top


Vitamin D is a pro-hormone that has a main role in the calcium and phosphorus metabolism in the body along with the regulation of formation and remodeling of bones through its role on calcium metabolism. The recommended daily allowance is 600 IU/day to achieve a serum level of >20 ng/ml.[1] The Food and Nutrition Board has set upper intake levels of Vitamin D at 2000 IU/day (50 μg/day).[2] Doses higher than 50,000 IU/day are known to raise serum concentrations >150 ng/ml, leading to hypercalcemia.[3] The Indian recommendation is 600–800 IU daily. The main sources of Vitamin D are skin which produces it from sunlight and animal products. Vitamin D apart from its major role in calcium and bone metabolism is also important for the good functioning of the cardiovascular system, immune system, and cancer prevention.[4],[5],[6] Due to its wide range of roles in the prevention of a variety of diseases and its widespread deficiency as people are spending lesser and lesser time in the sun the prescription of Vitamin D has increased manifold.

Cases of overdose of Vitamin D are also being reported. The toxicity happens because of a wrong prescription, faulty manufacturing, or overdosing on the patient's part.[7]

This case is being reported because the patient presented with severe weakness resembling pure motor spastic quadriparesis. The complete evaluation revealed hypercalcemia due to Vitamin D to be the cause for it.


  Case Report Top


A 28-year-old patient presented to our hospital with complaints of weakness of all four limbs for the past 15 days. The patient's complaints started with acute onset weakness of lower limbs followed by upper limbs over a day or two. The weakness was limiting him from carrying out his day-to-day activities. He was not able to hold objects or walk without support. There were no complaints of absent or altered sensations. No history of head trauma, fever, neck pain, weight carrying, dog bite, tuberculosis, diabetes mellitus, or HIV was present.

Examination revealed normal cardiovascular, respiratory, and abdomen examination. On neurological examination, the patient was conscious, cooperative and well oriented to time place, and person. Cranial nerves were intact. There were no problems with the cranium spine or signs of meningeal irritation. Motor system examination showed grade 3 power in all four limbs with increased tone and hyperreflexia on examination of the deep-tendon jerks. The plantar reflex was flexor. There was no muscle wasting or fasciculation. All modalities of sensations were normal.

On imaging, the MRI of the spine was normal. The nerve conduction studies were also not much helpful.

The patient's blood investigations showed a normal complete blood count with a total white blood cell count of 8200/mm3 with normal differential counts and no immature or plasma cells, hemoglobin levels of 13.8 mg/dl, and platelet counts to be 4.6 lakhs/mm3. The liver function tests were normal. The serum creatinine was however 2.1 mg/dl and the urine routine examination showing some trace proteins. Testing for electrolytes we got normal sodium and potassium levels. The calcium levels surprisingly were very elevated. It was 14.2 mg/dl. The ionic calcium was 7.22 mg/dl. Ultrasonography of the abdomen suggested multiple kidney stones with normal-sized kidneys and maintained corticomedullary differentiation.

We now had a case of pure motor spastic quadriparesis which most likely was due to hypercalcemia. We went about evaluating the cause for it. The patient's parathyroid hormone levels were extremely low 3.1 pg/ml (15–68.3). In view of that, we thought of a diagnosis of hypercalcemia of malignancy. X-ray of all long bones, thorax, and abdomen was taken to look for a lesion. It suggested bilateral inflammatory arthritis of the hip joints with secondary osteoarthritis and osteopenia. The X-rays did not find any pathology in the lung pleura or hear. Parathyroid hormone related protein (PTHrP) was also sent and the patient was planned for a positron emission tomography (PET) scan to look for an occult malignancy causing paraneoplastic syndrome. The PET scan could not find any metabolically active lesion in the body suggestive of paraneoplastic etiology in the whole-body survey.

Vitamin D levels were found to be in the elevated range of 132.58 ng/ml (30–70). These were the levels about a month after he had come to our hospital. On asking the patient, he now gave a history that he had consulted a few local doctors for his pains in the hip for which he had been prescribed some injections of vitamins. He did not have any details regarding the drugs or their strengths. We surmised that they must have been Vitamin D injections which had led to the present state.

The patient was started on treatment for hypercalcemia with steroids (prednisolone 30 mg/day orally for 21 days with down titration) and furosemide (60 mg/day orally) till the symptoms improved. Diazepam (10 mg) tablets were given to help the patient symptomatically. The patient's symptoms improved gradually and he was able to walk, first with aid of his relatives and later without any help.

The patient was counseled regarding his present state and referred to the department of orthopedics for further treatment of his pathology of the bones. He was asked to follow-up every month with our department.


  Discussion Top


Vitamin D acts by increasing the absorption of calcium from the gastrointestinal tract. The symptoms resulting from toxic levels are those that occur due to hypercalcemia and hypercalciuria. Muscle weakness, gastrointestinal upset, polyuria, polydipsia, renal calculi, renal failure, neuropsychiatric disturbances, cardiac arrhythmias, and coronary calcification are the predominant features.[8] The treatment involves the use of hyperhydration, furosemide, steroids, and in some cases hemodialysis. Intranasal and subcutaneous calcitonin has been used in cases.[9]

Our patient presented with weakness of all four limbs which resembled pure motor spastic quadriparesis. The evaluation finally yielded the diagnosis to be Vitamin D toxicity as a result of the wrong prescription by the local practitioner. Vitamin D levels were not in the toxic range on testing but only elevated probably because the testing was done after a few weeks had elapsed during which the other workup for his condition was being done. Vitamin D is known to get eliminated from the body as per its elimination pharmacokinetics.[10]

Anık et al. and Kara et al. have reported case series where the patients had toxicity resulting from the prescribed Vitamin D tablet containing many fold more vitamin that claimed.[11],[12] Ketha et al. reported a case of hypervitaminosis resulting from overmedication due to the wrong prescription.[13] Rocha and Santos reported a case of toxicity due to usage of Vitamin D on humans which had been only limited for use in animals.[14] There have also been a lot of reports of Vitamin D toxicity due to incorrect prescription by physicians.

Kaur et al. and Koul et al. have described patients developing toxicity due to Vitamin D being prescribed for a number of diseases.[15],[16] Differential diagnosis of hypercalcemia included multiple myeloma, granulomatous disease, renal disease, and hyperparathyroidism, but based on further evaluations, these diseases were ruled out. They had taken it for various conditions that included back pain, radiculopathy, osteoarthritis, and generalized weakness.

Bansal et al. also described an iatrogenic case of hypervitaminosis D.[17] It involved a 45-year-old female who had received a total of 6,000,000 IU of Vitamin D as an intramuscular injection within a period of 2 weeks. Laboratory results revealed 25(OH) D and total calcium levels to be 150 ng/mL and 23.1 mg/dL, respectively. It was later revealed that the intramuscular injection had been prescribed after her knee surgery.

Iatrogenic hypervitaminosis D was reported by Pandita et al. in elderly subjects in whom toxicity occurred due to excessive administration of Vitamin D by oral and intramuscular routes. The injections of Vitamin D (600,000 IU/injection) were prescribed by the physician to improve health and to reduce the frailty of the elderly.[18]


  Conclusion Top


Vitamin D is a commonly available supplement. Care should be taken to avoid the over-prescription and overuse of it to not cause cases like these where the patient ended up with an entirely new problem from the one he was being treated for.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, et al. The 2011 report on dietary reference intakes for calcium and Vitamin D from the institute of medicine: What clinicians need to know. J Clin Endocrinol Metab 2011;96:53-8.  Back to cited text no. 1
    
2.
Hathcock JN, Shao A, Vieth R, Heaney R. Risk assessment for Vitamin D. Am J Clin Nutr 2007;85:6-18.  Back to cited text no. 2
    
3.
Vieth R. Why the optimal requirement for Vitamin D3 is probably much higher than what is officially recommended for adults. J Steroid Biochem Mol Biol 2004;89-90:575-9.  Back to cited text no. 3
    
4.
Brewer LC, Michos ED, Reis JP. Vitamin D in atherosclerosis, vascular disease, and endothelial function. Curr Drug Targets 2011;12:54-60.  Back to cited text no. 4
    
5.
Judd SE, Nanes MS, Ziegler TR, Wilson PW, Tangpricha V. Optimal Vitamin D status attenuates the age-associated increase in systolic blood pressure in white Americans: Results from the third National Health and Nutrition Examination Survey. Am J Clin Nutr 2008;87:136-41.  Back to cited text no. 5
    
6.
Delvin E, Souberbielle JC, Viard JP, Salle B. Role of Vitamin D in acquired immune and autoimmune diseases. Crit Rev Clin Lab Sci 2014;51:232-47.  Back to cited text no. 6
    
7.
Galior K, Grebe S, Singh R. Development of Vitamin D toxicity from overcorrection of Vitamin D deficiency: A review of case reports. Nutrients 2018;10:953.  Back to cited text no. 7
    
8.
Minisola S, Pepe J, Piemonte S, Cipriani C. The diagnosis and management of hypercalcaemia. BMJ 2015;350:h2723.  Back to cited text no. 8
    
9.
Marins TA, Galvão TD, Korkes F, Malerbi DA, Ganc AJ, Korn D, et al. Vitamin D poisoning: Case report. Einstein (São Paulo) 2014;12:242-4.  Back to cited text no. 9
    
10.
Jones G. Pharmacokinetics of Vitamin D toxicity. Am J Clin Nutr 2008;88:582S-586S.  Back to cited text no. 10
    
11.
Anık A, Çatlı G, Abacı A, Dizdarer C, Böber E. Acute Vitamin D intoxication possibly due to faulty production of a multivitamin preparation. J Clin Res Pediatr Endocrinol 2013;5:136-9.  Back to cited text no. 11
    
12.
Kara C, Gunindi F, Ustyol A, Aydin M. Vitamin D intoxication due to an erroneously manufactured dietary supplement in seven children. Pediatrics 2014;133:e240-4.  Back to cited text no. 12
    
13.
Ketha H, Wadams H, Lteif A, Singh RJ. Iatrogenic Vitamin D toxicity in an infant – A case report and review of literature. J Steroid Biochem Mol Biol 2015;148:14-8.  Back to cited text no. 13
    
14.
Rocha PN, Santos CS, Avila MO, Neves CL, Bahiense-Oliveira M. Hypercalcemia and acute kidney injury caused by abuse of a parenteral veterinary compound containing Vitamins A, D, and E. J Bras Nefrol 2011;33:467-71.  Back to cited text no. 14
    
15.
Kaur P, Mishra SK, Mithal A. Vitamin D toxicity resulting from overzealous correction of Vitamin D deficiency. Clin Endocrinol (Oxf) 2015;83:327-31.  Back to cited text no. 15
    
16.
Koul PA, Ahmad SH, Ahmad F, Jan RA, Shah SU, Khan UH. Vitamin D toxicity in adults: A case series from an area with endemic hypovitaminosis D. Oman Med J 2011;26:201-4.  Back to cited text no. 16
    
17.
Bansal RK, Tyagi P, Sharma P, Singla V, Arora V, Bansal N, et al. Iatrogenic hypervitaminosis D as an unusual cause of persistent vomiting: A case report. J Med Case Rep 2014;8:74.  Back to cited text no. 17
    
18.
Pandita KK, Razdan S, Kudyar RP, Beigh A, Kuchay S, Banday T. “Excess gooD can be Dangerous”. A case series of iatrogenic symptomatic hypercalcemia due to hypervitaminosis D. Clin Cases Miner Bone Metab 2012;9:118-20.  Back to cited text no. 18
    




 

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