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A 40-year-old female with a long history of photophobia for several years, presented with muscle aches and fatigue for the last few months. Fatigue has been gradually developing, and the patient became unable to perform her daily activities. The patient has been treated for seizures for several years and depression for few years.Â
Review of her laboratory values are shown in table 1
|
Test |
Value |
|
S. Creatinine |
0.9 mg/dL |
|
S. Corrected Calcium |
8.1 mg/dL |
|
S. Phosphorus |
3.1 mg/dL |
|
25(OH) vit D |
4 ng/mL |
|
iPTH |
68 pg/ml |
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Interpret the above laboratory work-up.
Overt vitamin D deficiency, with hypocalcemia and hypophosphatemia.
What are the risk factors for developing the above laboratory abnormality
-Labs show: sever vitamin D deficiency, resultant
hypocalcemia, hyperparathyroidism mostly SHPT (in response to low Ca and vitamin D levels).
-Risk factors for those abnormalities could be
secondary hyperparathyroidism due to Hypocalcemia secondary to Vit D deficiency
1- acceptable lab except sever vitamin D deficiency
2- drug interaction and less sun exposure
kidney and liver disease can be also
1 Vitamin D Deficiency and hypocalcaemia
2 Decrease Sun intake and dietary intake
Drugs that interact with cytochrome enzyme?
patients lab work – up , severe vitamin d deficiency ,which is the cause both hypocalcemia and hypophosphatemia .
patients was avoiding sun exposure due to photophobia
risk factors > lack of sun exposure ,kidney and liver diseases, antidepressant and epileptics .
1- hypocalcemia and vit D defiency
2-decreased sun exposure due to photophobia
premenpausal period with hormonal disturbance
decreased mobility
antipsychotic drugs
Severe vitamin D deficiency due to hypocalcemia and hypophosphatemia.
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1. Interpret the above laboratory work-up.
Severe vitamin D deficiency that could be the cause of both hypocalcemia and hypophosphatemia. The patient has symptoms of vitamin D deficiency which are fatigue and muscle aches. Other symptoms may occur like osteomalacia, bone fragility and fractures. Also, depression is a complication of vitamin D deficiency.
2. What are the risk factors for developing the above laboratory abnormality?
Vitamin D deficiency occurred by different mechanisms such as either decreased intake or diminished sun exposure and consequently cutaneous synthesis. Also, decreased synthesis and absorption contribute to vitamin D deficiency. Moreover, kidney and liver disease which lead to inability to process vitamin D. Some of antiepileptic drugs such as phenytoin, phenobarbital, and carbamazepine are strong stimulants for hepatic microsomal enzymes, resulting in changes in the metabolism of exogenous or endogenous substances. These drugs usually decrease serum level of Ca and vitamin (Vit) D. Moreover, the antidepressant drugs fluvoxamine and fluoxetine are both reported to inhibit the metabolism of CYP enzymes involved in this process.
severe Vit. D deficiency with mild hypocalcemia and high normal PTH. normal S. creatinine.
risk factors for developing the above laboratory abnormality? lack of sun exposure due to photophobia. Drugs.poorn oral intake
Severe vitamin D3 deficiency
low serum calcium
high normal PTH
norma RFT
Avoid sun exposure due to photophobia
poor dietary intake
drug intake that interfere with hepatic hydroxylation of vitamin D
1- lab interpretation sever vit D deficiency low normal ca other lab was normal.
2-risk factor for developing these symptoms mostly unexposure to sun light dueto photophobia increase metabolism of vit D dueto consumption of anti epileptics drugs decrease intake
Interpretation
Risk factors-this can be divided into seven groups
Interpret the above laboratory work-up.
What are the risk factors for developing the above laboratory abnormality?
VERY LOW VIT D IS THE CAUSE FOR THOSE CHANGES , THE RISK FACTORS FOR THOSE ABNORMALITY MOSTLY NO SUN EXPOSURE , DIET NOT REACHED WITH VIT D , MEDICATION
1.normal kidney function with low s.ca nd p, sever hypo vitamin D
2.Risk Factor
poor oral intake (depression),not exposed to sun (she has photophobia)
medication as antiepileptic therapy
1 normal kidney function, slightly low Ca and phosphorous, very low vitamin D level
2 use of anticonvulsant causes low vitamin D level and because of depression that lead to poor oral intake and little sun exposure
The above laboratory workup
Severe vitD deficiency
Risk factors
2. Medications
3. Weight-lowering surgery.
The patient has low vitamin d (deficiency) with a secondary elevation of PTH. Both Ca/P are low, consistent with vitamin d deficiency.
Low d vitamin consumption, photophobia and sunlight avoidance exaggerate vitamin D deficiency. Anticonvulsants interfere with vitamin d metabolism
This patient has hypocalcemia and hypophophatemia due to low Vit D ,along with mild eleveation of PTH .
nutritional cause
little sun exposure
liver failuer
drug induced
This patient is recieving ASM which is lead to subtle radiogarphic and biochemical abnormality as these medications reduce the bone mineralization and bone density ,affecting Vit D abnormality and increase bone remodeling activity all these will increase the risk of fractuer .
On THE other hand ,ASM is associated with secondery osteoporosis adding to that a lot of study showed increased risk of fractuer among patient with epilepsy .
Alot of observation study showed increase RR of hip fractuer in epilepsy patient .
In patient with epilipsy on ASM increase of bone turnover marker like ALP .
high serum level of bone formationlike osteocalcin and C terminal extension peptide of type I pro collagen (PICP) ,elevated marker of bone resorption C-terminal telopeptide of human type 1 collagen ..
THIS patient could be having osteomalacia in association with ASM which generally associated with profound vit d deficiency Serum Ca and phosphorous and serum 25 hydroxyvitamin D low along with high PTH .
hypocalcemia and hypophosphatemia secondary to severe low vitamin D with high iPTH.
causes of low vitamin -D;
not enough exposure to sunlight.
Darker skin pigment.
Malnutrition.
liver failure, which prevents the body from adequately processing vitamin D.
Certain medications.
Certain types of cancer, such as lymphoma.
A family history of vitamin D deficiency or childhood rickets
1.Interpret the above laboratory work-up
2.What are the risk factors for developing the above laboratory abnormality?
1. Interpret the above laboratory workup.
Low vitamin D level-
2. What are the risk factors for developing the above laboratory abnormality?
Lack of direct sun exposure
Low vitamin D diet food
Drugs that reduced levels of vitamin D such as anti-seizure medication
Interpret the above laboratory work-up.
1-hypoviatminosis D and hypocalcemia.
What are the risk factors for developing the above laboratory abnormality?
low vit-D supplementation .
lack of sun exposure.
drug induced low vit-D
1-hypoviatminosis D ,mild hypocalcemia
PTH on ULN
normal creatinine and po4
2-risk factors
1-antiepliptic drugs
2-diet
3-lack of sun exposure
The laboratory revealed
hypo calcemia , hypo vit.D and mild compensatory rise of iPTH
The risk factor for developed hypo calcemia and hypo vitD
Factors related to source >>>dietitian , lake of sun exposure
factors related to GIT absorption
factors related to regulation of vit.d >>>hepatic or renal
Interpret the above laboratory work-up.
What are the risk factors for developing the above laboratory abnormality?