Vitamin D Toxicity: Caveat Emptor

James P. Leu, MD; Arthur Weiner, MD; Uriel S. Barzel, MD

Disclosures

Endocr Pract. 2008;14(9):1188-1190. 

In This Article

Case Presentation

A 60-year-old woman from the Dominican Republic, with a history of osteoarthritis and with a normal serum calcium level 3 months before the current encounter, presented with a 2-week history of increasing weakness, abdominal pain, and polyuria. Her history was negative for recent illnesses, new medications, or change in diet. She denied taking any supplements. Initial laboratory evaluation showed a serum calcium level of 15.2 mg/dL (reference range, 8.5 to 10.5), a minimally elevated blood urea nitrogen level of 27 mg/dL, and an anemia (hematocrit of 29.3%). The serum intact parathyroid hormone (PTH) level was undetectable, and the PTH-related peptide level was low. A computed tomographic scan of the abdomen and pelvis was unremarkable. A skeletal survey was negative, and a bone marrow biopsy specimen showed normal findings. The 25-hydroxyvitamin D blood level was >150 ng/mL (reference range, 20 to 100), and the 1,25-dihydroxyvitamin D level was within the normal range. The blood urea nitrogen and serum calcium analyses were done by an automated method. The intact PTH study was performed on the Siemens Diagnostics Immulite 2000 system (Siemens Healthcare Diagnostics, Inc., Deerfield, Illinois). The 25-hydroxyvitamin D assay was performed on the DiaSorin Liason instrument (DiaSorin Inc., Stillwater, Minnesota), and the 1,25-dihydroxyvitamin D assessment was performed by liquid chromatography-tandem mass spectrometry at Quest Diagnostics (Madison, New Jersey).

The hypercalcemia and clinical symptoms improved with aggressive intravenous administration of saline and intermittent injections of furosemide. A single dose of 60 mg of pamidronate was administered intravenously. Endoscopy revealed gastritis. An anal squamous cell carcinoma in situ was resected. She was discharged on hospital day 10, with a serum calcium level of 10.6 mg/dL and instructions to avoid any supplementation with calcium or vitamin D.

Subsequently, the patient reported that, when she had complained of generalized fatigue before her hospitalization, her relatives had recommended that she purchase an OTC prescription vitamin supplement, Soladek (Indo-Pharma, S.A., Dominican Republic) (Fig. 1). Five milliliters of Soladek contains 120,000 IU of vitamin A, 600,000 IU of vitamin D, and 5.0 mg of vitamin E. She had consumed 2 vials of 5 mL initially and 1 vial weekly for 10 more weeks until her hospital admission.

Figure 1.

Soladek from Indo-Pharma, S.A., Dominican Republic, showing vitamin content.

After the patient was discharged from the hospital, her serum calcium level remained normal. Four months later, her 25-hydroxyvitamin D blood level was in the reference range, as was the intact PTH level (Fig. 2).

Figure 2.

Laboratory values--25-hydroxyvitamin D blood level (ng/mL), serum calcium level (mg/dL), and serum intact parathyroid hormone (PTH) level (pg/mL)--over time for the patient.

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