On laboratory investigation the following results were obtained: 25 (OH) Vit D was 189 ng/mL, ESR 65 mm. Urine analysis did not show any blood or protein. Protein electrophoresis did not reveal any monoclonal bands. Brain, abdominal and chest imaging were all normal.
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1- good hydration, IV saline maintaining UOP at a rate of 100-150 ml/ hour
2- SC calcitonin at a dose of 4 units
3- steroid, prolong the effect of calcitonin
4- if persistent, bisphosphonate could be used
The most likely cause is vitamin D intoxication secondary to injudiciously OTC intake of vitamin D.
in-hospital management plan:
Vid D intoxicating
Rehydration with diuretic
1- hypercalcemia due to vitamin D intoxication
2- hydration with IV fluid and furosemide to increase ca excretion
Patient has Hypervitaminosis D leading to hypercalcemia. High ESR indicating that the patient is having either infection or chronic inflamatory process. In view of high ESR, hypercalcemia, and AKI, chronic infection or inflammation would be the cause of AKI. Granulomatous disease, like TB, lymphoan ma and sarcoidosis are not in the DDx, as the patient is having high PTH, and normal brain, Abdx, and chest imaging.
I still do not have an explanation for high, not suppressed, iPTH with hypercalcemia- it does not go with the case scenario.
hypercalcaemia due to hypervitaminosis.
2
iv fluids
stop vitamin d
prednisolone?
Biphosphonate
the most likely cause of patients lab abnormalities is vitamin d intoxication or hypervitaminosis due to over the counter drug
its an emergency condition which requires admission and fluid expansion ,restrict dietary intake of vitamin d,biphosphonates
1- it is mostly a case of hypercalcemia due 2 vit D intoxication related to excess intake
2- good hydration , bisphosphonates , loop diuretics , calcitonin , steroids , denosumab , HD is still persistant and symptomatic with low dialysate calcium
Mostly vitamin D intoxication due to high doses of vit D Intake
1.What is the most likely cause of the patient’s lab abnormality? Why?
The most likely diagnosis is hypervitaminosis D (25 (OH)vitamin D highly elevated) that causes hypercalcemia and polyuria. Other investigations excluded other causes of hypercalcemia. AKI is caused by hypercalcemia due to degeneration and necrosis of tubular cells and eventually tubular atrophy. also, interstitial fibrosis and calcification caused by hypercalcemia predispose to renal failure.
2. Suggest an in-hospital management plan for this patient.
bisphosphonates or denosumab can be considered in resistant cases.
What is the most likely cause of the patient’s lab abnormality? Why?
Polyuria is a result of hypercalcemia, resulted from vit d
Suggest an in-hospital management plan for this patient.
Stopping vitamin D intake. Intravenous fluids, Diuretics, Corticosteroids, Bisphosphonates.
Vit D intoxication
due to Lab result of hypercalcimia and high vitamin D level.
consider as medical emergency treated by admission to ICU with aggressive hydration and use of loop diuretics, if no response, hemodialysis with low ca. dialysate.
1- the most likely cause the lab abnormality vit d intoxication.
Why dueto hypercalcimia present and symptomatology of patient in form of polyurea and lethargy.
2-hospital management it’s condition consider as emergency admissions in ICU good hydration with loope diuretic if cannot tolerate hydration and inadequate urine output do hemodialysis with low ca diyalisate
Abnormal labs:
Management:
What is the most likely cause of the patient’s lab abnormality? Why?
Vitamin D toxicity results in hypercalcemia, and the symptom of polyuria is a result of hypercalcemia.
Suggest an in-hospital management plan for this patient.
SO AFTER THOSE RESULT IT IS VIT D TOXICITY , VERY HIGH LEVEL VIT D , NEEDS FOR INHOSPITAL MANAGMENT AFTER STOPING VIT D AND DIETARY INSTRUCTION , NEEDS FOR IV FLUIED HIGH RATE BUT AS HE IS CARDIAC PATIENT WILL NEEDS FOR CARDIOLOGY EVALUATION INCULDING ECHOCARDIOGRAPHY TO DECIDE FOR THE IV FLUIED RATE USUALY MORE THAN 200 ML/HR AS START AND OBSERVE THE KFT AND CALCIUM LEVEL , IF NO RESPONCE MAY GO FOR OTHER WAYS OF TREATMENT OF HYPERCALCEMIA INCLUDING DIALYSIS WITH LOW CALCIUM BATH
A. Vitamin D intoxication, because vitamin D level above 120ng/ml from excessive administration of vitamin D
B. Stop vitamin D supplements
Dietary advice
Intravenous hydration
If no response biphosphonate
What is the most likely cause of the patient’s lab abnormality? Why?
Suggest an in-hospital management plan for this patient.
Most of people with Hypercalcemia are dehydrated and this is also the case , giving a loop diuretic and further dehydrate the patient will cause further increase in Serum Creatinin and more tachycardia and further lowering the blood pressure.
Biphosphonate can be considered but with kidney injury i don’t think its appropriate.
After Hemodialysis i will control the Creatinin level to see if there is any improvement. In the case that there is no improvement i can consider a kidney biopsy but it is not obligate but i can help later for tranplantation .
Thank you dr Nour.
The patient presented with dehydration caused by hypercalcemia and polyuria.
the first line in the management is Volume expansion with isotonic saline at an initial rate of 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hour. loop diuretics indicated in case of heart failure or renal failure with signs of volume overload. adding intramascular or subcutaneous calcitonin is helpful aslo.
if these measures fail, you may consider dialysis.
Vitamin more than 150 ng/ml, so the main cause is most likely high consumption of vitamin d consumption. Hydration and furosemide to increase calciuresis is the first step. cessation of vitamin d supplementation. unless ECG changes present this conservative treatment is enough. The second line is bisphosphonate etc. , here may not be needed.
The likely cause
Vitamin intoxication
In hospital management
1.v.D toxicity
due to high S.VD, high s.ca and he was intake high dose VD 6000 IU twice per day or long time
2.stop VD intake and CA supplement
-good hydration oral and IV and monitor electrolyte levels ,keep high flow UOP
-steroids can be an option
-after being euvolemic ,BP improved and tachycardia controlled diuretics can be an option
Vitamin D toxicity results in hypercalcemia, and the symptom of polyuria is a result of hypercalcemia.
A vitamin D serum content of 189 ng/ml, which is over the normal maximum limit.
Hypercalemia (>10.5 mg/dl).
ESR is elevated
The patient has symptomatic moderate hypercalcemia.
Adequate hydration (at least six to eight glasses of water per day) is recommended to minimize the risk of nephrolithiasis.
IV. Rehydration with normal saline to correct the hypotension and dehydration, and maintain high-flow urine output
Additional therapy depends mostly upon the cause of the hypercalcemia(Bisphsphonate)
This patient’s lab result showed hypervitaminosis D with hypercalcemia
so will hold Vit D Aas he was on a high dose of daily Vit D supplementation.
This patient needs to be admitted to HDU under cardiac monitoring
hole all anti HTn medications for now
Continue with bisoprolol but with the lower dose
prober hydration with IP //OP chart
correct the K
need daily ca and k,mg monitoring
What is the most likely cause of the patient’s lab abnormality? Why?
Vitamin D intoxication leading to hypercalcemia because:
Suggest an in-hospital management plan for this patient.
1- mostly vitamin D intoxication due to high doses of vit D INTAKE
2-
A-stop vit D intake
good hydration by normal saline (3–4 l /day according to volume status )
frusemide after hydration
cinacalcet
fu serum calcium regularly
What is the most likely cause of the patient’s lab abnormality? Why
hypervitaminosis D ( Recommended Dietary Allowance (RDA) for adults of 600 IU of vitamin D a day.)
Suggest an in-hospital management plan for this patient.
1. What is the most likely cause of the patient’s lab abnormality? Why?
Vitamin D overdose is the mostly likely the cause of this lab abnormality
2.Suggest an in-hospital management plan for this patient.
Stop Vitamin D
Furosemide
calcitonin
Flow up: serum 25 (OH) Vit D, calcium, PTH,serum creatinine
THE CAUSE OF LAB ABORMALITY
vit. D over dose intoxication and aki
stop vit. d
fluid resuscitation and fu vital signs and renal function
supportive treatment
What is the most likely cause of the patient’s lab abnormality? Why?
Suggest an in-hospital management plan for this patient.
with follow-up of serum calcium and other electrolytes with correction of deficits.