A family with massive acute vitamin D intoxication

Down, P. F.; Polak, Agnieszka; Regan, Richard J.

doi:10.1136/pgmj.55.650.897

Cited by 24 publications

(18 citation statements)

References 15 publications

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“…Although VDI in industrialized countries has been usually associated with food products [1][2][3][4][5][6] or dietary supplements, [7][8][9][10][11][12] in Turkey it has always resulted from mistakenly used or unnecessary use of high-dose vitamin D 3 -containing ampules. [15][16][17][18][19][20][21][22] This is the first report, to our knowledge, from Turkey that describes dietary supplement-induced vitamin D toxicity.…”

Section: Discussionmentioning

confidence: 99%

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Vitamin D Intoxication Due to an Erroneously Manufactured Dietary Supplement in Seven Children

et al. 2014

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Pediatric cases of vitamin D intoxication (VDI) with dietary supplements have not been previously reported. We report on 7 children with VDI caused by consumption of a fish oil supplement containing an excessively high dose of vitamin D due to a manufacturing error. Seven children aged between 0.7 and 4.2 years were admitted with symptoms of hypercalcemia. Initial median (range) serum concentrations of calcium and 25-hydroxyvitamin D were 16.5 (13.4-18.8) mg/dL and 620 (340-962) ng/mL, respectively. Repeated questioning of the parents revealed use of a fish oil that was produced recently by a local manufacturer. Analysis of the fish oil by gas chromatography/mass spectrometry revealed that the vitamin D 3 content was ∼4000 times the labeled concentration. Estimated daily amounts of vitamin D 3 intake varied between 266 000 and 800 000 IU. Patients were successfully treated with intravenous hydration, furosemide, and pamidronate infusions. With treatment, serum calcium returned to the normal range within 3 days (range: 2-7 days). Serum 25-hydroxyvitamin D levels normalized within 2 to 3 months. Complications, including nephrocalcinosis, were not observed throughout the 1-year followup. In conclusion, errors in manufacturing of dietary supplements may be a cause of VDI in children. Physicians should be aware of this possibility in unexplained VDI cases and repeatedly question the families about dietary supplement use. To prevent the occurrence of such unintentional incidents, manufacturers must always monitor the levels of ingredients of their products and should be rigorously overseen by governmental regulatory agencies, as is done in the pharmaceutical industry. Pediatrics 2014;133:e240-e244 Vitamin D intoxication (VDI) is a rare condition today. Over the past 40 years, it has been usually described as a result of unintentional conditions, such as contamination of cooking oil, 1-3 overfortification of milk, 4,5 or adulteration of table sugar. 6 VDI associated with overthe-counter dietary supplements has been reported in adult patients. [7][8][9][10][11][12] However, to our knowledge, pediatric cases of VDI caused by dietary supplements have not been previously reported. We report here on 7 young children with VDI caused by the consumption of a fish oil supplement that contained an excessively high dose of vitamin D due to a manufacturing error. CASE HISTORIESA 2.5-year-old boy was admitted on September 24, 2011, with a history of fever, weakness, constipation, loss of appetite, nausea, and vomiting for 2 weeks. He was clinically dehydrated. His serum calcium and 25-hydroxyvitamin D (25[OH]D) levels were 13.4 mg/dL (normal range: 8.8-10.8 mg/dL) and 962 ng/mL (normal range: 30-80 ng/mL), respectively. His parents denied taking any drug or dietary supplement containing vitamin D.The second male infant, aged 13 months, was admitted 2 weeks later with a history of weakness, poor appetite, vomiting, weight loss, and constipation for 12 days. His physical examination was normal. His serum calcium and 25(OH)D l...

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Section: Discussionmentioning

confidence: 99%

“…Over the past 40 years, it has been usually described as a result of unintentional conditions, such as contamination of cooking oil, [1][2][3] overfortification of milk, 4,5 or adulteration of table sugar. 6 VDI associated with overthe-counter dietary supplements has been reported in adult patients.…”

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confidence: 99%

Vitamin D Intoxication Due to an Erroneously Manufactured Dietary Supplement in Seven Children

et al. 2014

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“…Toxic effects of hypercalcemia from hypervitaminosis D are usually evident when intake of vitamin D exceeds 25,000 IU/day and the serum 25-hydroxyvitamin D level is at least 200 ng/mL [6]. Hypervitaminosis D has been attributed to over-fortification of milk [7,8], infant formula [9], overthe-counter vitamin D supplements [10,11], contaminated foods [12], and dosing errors [13]. A recent Food and Drug Administration MedWatch Safety Alert warns parents of the risk of infant overdoses related to liquid vitamin D [14].…”

Section: Describe the Various Drug-induced Causes Of Hypercalcemia Hmentioning

confidence: 99%

Vitamin D Toxicity in an Infant: Case Files of the University of California, San Francisco Medical Toxicology Fellowship

Smollin

Srisansanee

2014

J. Med. Toxicol.

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A previously healthy 2-month-old female with no significant past medical history and a normal birth history presented to her family doctor with 2-3 weeks of decreased activity and poor feeding. She was also noted to have diminished weight gain, decreased frequency of stools with only one stool over the previous 10 days prior to presentation, and a decrease in her urine output. There was no history of fever, upper respiratory symptoms, vomiting, or diarrhea, and there were no other sick contacts in the household. On physical examination, the patient was a well-developed and well-nourished female infant weighing 5 kg (33rd percentile). Vital signs were as follows: blood pressure 102/62 mmHg, pulse 140 beats per min, respiratory rate 24 breaths per min, and her temperature was 37.6°C. The patient was described to have slightly diminished muscle tone throughout and decreased sucking reflex. No other abnormalities were noted.

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“…In the United States, milk is fortified with vitamin D, and some forms of butter, margarine, cereals, and fruit juices also are fortified. Unfortunately, most individuals in the United States do not eat the necessary 2 servings of a vitamin D-fortified food in a day to ensure adequate dietary intake of vitamin D. 10 To make up for this deficit, these people should rely on adequate sun exposure; however, if these patients adhere to the recommendation of the Centers for Disease Control and Prevention on decreasing direct sun exposure, then they would need a dietary supplement of vitamin D to ensure proper bone health.Unintentional vitamin D poisoning has been associated with overfortification of milk, 11,12 adulteration of table sugar, 13 and contamination of cooking oil [14][15][16] and with use of an over-the-counter supplement by an adult. 17 We present the unique case of an unintentional vitamin D overdose in a child, caused by improper dosing with an imported vitamin D supplement.…”

mentioning

confidence: 99%

“…Unintentional vitamin D poisoning has been associated with overfortification of milk, 11,12 adulteration of table sugar, 13 and contamination of cooking oil [14][15][16] and with use of an over-the-counter supplement by an adult. 17 We present the unique case of an unintentional vitamin D overdose in a child, caused by improper dosing with an imported vitamin D supplement.…”

mentioning

confidence: 99%

Acute Vitamin D Intoxication in a Child

Barrueto¹,

Wang-Flores

Howland

et al. 2005

Pediatrics

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ABSTRACT. We present the unique case of a previously healthy, 2-year-old boy with resistant hypercalcemia and hypertension resulting from an unintentional overdose with an imported vitamin D supplement. The patient presented initially to the emergency department with colic and constipation and was discharged after a benign physical examination. The symptoms persisted and, on the second visit, the patient was found to have a serum calcium level of 14.4 mg/dL. Despite therapy with intravenously administered 5% dextrose solution at onehalf normal strength, furosemide, calcitonin, and hydrocortisone, the calcium concentration increased to 15.0 mg/dL on the second hospital day and did not decrease until the fourth hospital day, when it fell to 13.9 mg/dL. The vitamin D concentration peaked at 470 ng/mL on hospital day 3. With additional questioning, the mother revealed that she had been giving her son a daily dose of 1 ampule of Raquiferol, an imported vitamin D supplement, instead of the recommended 2 drops per day. Each ampule contained 600 000 IU of vitamin D; therefore, the boy received a total of 2 400 000 IU over 4 days. The patient's hypercalcemia persisted for 14 days and was complicated by persistent hypertension. No renal, cardiac, or neurologic complications were noted. At discharge, the vitamin D concentration was still elevated at 389 ng/mL and the total calcium level had decreased to 11 mg/dL. The boy made a complete clinical recovery. This case highlights the need for caution when using imported and/or unregulated medicines, as well as the dangers of parental dosing errors. 7 Although the skin has the ability to metabolize cholesterol to a vitamin D precursor, it is unclear exactly how much sunlight one needs daily to metabolize sufficient amounts of vitamin D effectively. 8 In addition, health care providers and organizations, including the Centers for Disease Control and Prevention, have recommended decreased exposure to direct sunlight and the liberal use of sunscreens to prevent skin cancer. 9 Because vitamin D is used so readily, it is important to understand how dosing errors can lead to overdoses with potentially life-threatening consequences.Vitamin D is 1 of 4 fat-soluble vitamins. With parathyroid hormone, it regulates calcium homeostasis tightly. When the serum calcium level is low, calcitriol, the biologically active form of vitamin D, restores homeostasis through increased dietary calcium absorption through the gut and through increased bone resorption. Dietary sources of vitamin D are limited to fish, oysters, and dairy products. In the United States, milk is fortified with vitamin D, and some forms of butter, margarine, cereals, and fruit juices also are fortified. Unfortunately, most individuals in the United States do not eat the necessary 2 servings of a vitamin D-fortified food in a day to ensure adequate dietary intake of vitamin D. 10 To make up for this deficit, these people should rely on adequate sun exposure; however, if these patients adhere to the recommendation of the Cente...

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A family with massive acute vitamin D intoxication

Cited by 24 publications

References 15 publications

Vitamin D Intoxication Due to an Erroneously Manufactured Dietary Supplement in Seven Children

Vitamin D Intoxication Due to an Erroneously Manufactured Dietary Supplement in Seven Children

Vitamin D Toxicity in an Infant: Case Files of the University of California, San Francisco Medical Toxicology Fellowship

Acute Vitamin D Intoxication in a Child

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