Efficacy and safety of pamidronate in children with vitamin D intoxication

Life-threatening hypercalcemia in a child with vitamin D intoxication due to parental self-medication: A case report

Vitamin D is essential for bone metabolism and has gained popularity since the general population is now more aware of its benefits. Unfortunately, the availability of unregulated vitamin D formulations without prescription increases the risk of inadvertently ingesting excessive doses of vitamin D. Reports of pediatric cases of vitamin D toxicity are scarce in the world literature. We present the case of a 4-years 9-months old boy from a rural town with vitamin D intoxication secondary to ingestion of seven oral vials containing each of them 600,000 Units of cholecalciferol for a period of 8 months. It is important to educate general population about the risks of ingesting vitamin D without medical prescription. In our patient, the most effective treatment strategy was the use of pamidronate.

Fatality owing to pulmonary hemorrhage following pamidronate disodium administration in a neonate with osteogenesis imperfecta type 2: A case report

We report the case of a patient with osteogenesis imperfecta (OI) who developed pulmonary hemorrhage 4 d after pamidronate disodium (PA) administration, despite a relatively stable respiratory status. Bisphosphonates are introduced to reduce osteoclast activity and are now widely used in patients with OI. Bisphosphonates are typically well-tolerated in children, and the standard of care involves cyclic intravenous administration of PA. However, in practice, there is limited experience with the use of PA for severe OI during the neonatal period, and its safety remains uncertain. This report aimed to describe the respiratory events potentially associated with PA in a neonatal patient with OI type 2, suggesting that serious life-threatening complications of pulmonary hemorrhage may occur after PA administration. Further studies are required to assess the relationship between pulmonary hemorrhage and PA administration, aiming to enhance prophylaxis measures.

Vitamin D Intoxication Presenting as Subacute Encephalopathy-A Case Report

Vitamin D intoxication is uncommon in children and is more commonly suspected in the setting of ingestion of high doses of vitamin D. Its manifestations can be non specific and varied ranging from mild like constipation and vomiting to life threatening like arrhythmias and encephalopathy. Here we present a 14 month female who presented with loss of milestones, floppiness, and poor interaction with mother. She was detected to have hypercalcemia and was subsequently diagnosed with vitamin D intoxication. She was successfully treated with hydration, furosemide, prednisolone and frequent monitoring of electrolytes, electrocardiography and volume status. Subsequently as her serum calcium levels normalized with therapy, she became alert, conscious and started achieving developmental milestones.

Vitamin D intoxication due to misuse: 5-year experience

INTRODUCTION

Vitamin D intoxication (VDI) is a well-known cause of hypercalcemia in children and leads to serious kidney, heart, and neurological problems. In the treatment of VDI, the goal is to correct hypercalcemia. Our aim was to evaluate the clinical features of patients with VDI, identify the causes of VDI in our region, and help guide precautions and treatment of VDI.

MATERIALS AND METHODS

The medical records of patients with VDI presenting between January 2015 and December 2019 were retrospectively analyzed.

RESULTS

In total, 38 patients aged 0.3-4 years including 20 males (52.6%) were included in the study. Vomiting (65.8%), loss of appetite (47.4%), and constipation (31.6%) were the most common symptoms. The cause of intoxication was prescribed D₃ vials in 23 patients, non-prescribed D₃ vials in nine patients, and incorrectly produced fish oil supplement in six patients. Admission serum calcium and 25 (OH) D levels were 3.75±0.5mmol/L and 396±110ng/mL, respectively. A statistically significant correlation was found between the serum calcium levels at the time of diagnosis and the dose of vitamin D received, serum 25 (OH) D, phosphorus, and parathyroid (PTH) levels. Nephrocalcinosis was present in 15 (39.5%) patients. The mean time to achieve normocalcemia was 6.18±2 days. The mean time to achieve normocalcemia in patients treated with pamidronate was 5.94±0.7 days.

CONCLUSION

Stoss therapy should not be administered for children of families with problems of adherence to treatment. It should be noted that VDI may develop as a result of improperly produced nutritional supplements. General practitioners and pediatricians must be aware of VDI risks and explain them to parents. Pamidronate is effective for treating VDI in children.

Successful management with bisphosphonate treatment in a child with tuberculosis-associated hypercalcemia

Hypercalcemia is a common metabolic abnormality in children and generally occurs due to hyperparathyroidism, vitamin D toxicity, some genetic disorders and malignant diseases. Granulomatous diseases are a rare cause of hypercalcemia in children, which are usually mild and asymptomatic. Severe hypercalcemia in granulomatous diseases has also been reported in the literature. Here, we report a child presenting with severe hypercalcemia secondary to miliary tuberculosis with successful management with bisphosphonate treatment. Increased 1,25(OH)2D3 synthesis by activated macrophages in the granuloma tissue is the major mechanism of hypercalcemia in tuberculosis.

Comparison of Treatment Regimens in Management of Severe Hypercalcemia Due to Vitamin D Intoxication in Children

OBJECTIVE

No large study has been conducted to date to compare the effectiveness of prednisolone, alendronate and pamidronate as first-line treatment in children with hypercalcemia due to vitamin D intoxication. The aim was to perform a multicenter, retrospective study assessing clinical characteristics and treatment results.

METHODS

A standard questionnaire was uploaded to an online national database system to collect data on children with hypercalcemia (serum calcium level >10.5 mg/dL) due to vitamin D intoxication [serum 25-hydroxyvitamin D (25(OH)D) level >150 ng/mL] who were treated in pediatric endocrinology clinics.

RESULTS

Seventy-four children [median (range) age 1.06 (0.65-1.60) years, 45 males (61%) from 11 centers] were included. High-dose vitamin D intake was evident in 77% of the cases. At diagnosis, serum calcium, phosphorus, alkaline phosphatase, 25(OH)D and parathyroid hormone concentrations were 15±3.2 mg/dL, 5.2±1.2 mg/dL, 268±132 IU/L, 322 (236-454) ng/mL, and 5.5 (3-10.5) pg/mL, respectively. Calcium levels showed moderate correlation with 25(OH)D levels (r_s=0.402, p<0.001). Patients were designated into five groups according to the initial specific treatment regimens (hydration-only, prednisolone, alendronate, pamidronate, and combination). Need for another type of specific drug treatment was higher in children who initially received prednisolone (p<0.001). Recurrence rate of hypercalcemia was significantly lower in children who were treated with pamidronate (p=0.02).

CONCLUSION

Prednisolone is less effective in the treatment of children with severe hypercalcaemia secondary to vitamin D intoxication and timely implementation of other treatment regimens should be considered.

Hypercalcemia: a consultant's approach

Due to their daily involvement in mineral metabolism, nephrologists are often asked to consult on children with hypercalcemia. This might become even more pertinent when the hypercalcemia is associated with acute kidney injury and/or hypercalciuria and renal calcifications. The best way to assess the severity of hypercalcemia is by measurement of plasma ionized calcium, and if not available by adjusting serum total calcium to albumin concentration. The differential diagnosis of the possible etiologies of the disturbance in the mineral homeostasis starts with the assessment of serum parathyroid hormone concentration, followed by that of vitamin D metabolites in search of both genetic and acquired etiologies. Several tools are available to acutely treat hypercalcemia with the current main components being fluids, loop diuretics, and antiresorptive agents. This review will address the pathophysiologic mechanisms, clinical manifestations, and treatment modalities involved in hypercalcemia.

Consensus guidelines on the use of bisphosphonate therapy in children and adolescents

Bisphosphonate therapy is the mainstay of pharmacological intervention in young people with skeletal fragility. The evidence of its use in a variety of conditions remains limited despite over three decades of clinical experience. On behalf of the Australasian Paediatric Endocrine Group, this evidence-based consensus guideline presents recommendations and discusses the graded evidence (using the GRADE system) for these recommendations. Primary bone fragility disorders such as osteogenesis imperfecta are considered separately from osteoporosis secondary to other clinical conditions (such as cerebral palsy, Duchenne muscular dystrophy). The use of bisphosphonates in non-fragility conditions, such as fibrous dysplasia, avascular necrosis, bone cysts and hypercalcaemia, is also discussed. While these guidelines provide an evidence-based approach where possible, further research is required in all clinical applications in order to strengthen the recommendations made.