Osteomalacia in chronic liver disease

Clinical evaluation of liver disease

The clinical history and examination is essential in the evaluation of patients with liver disease. This chapter details important points in the clinical history and examination allowing the physician to identify likely causes of liver damage and their investigation. The evaluation should allow the physician to differentiate acute and chronic liver diseases, and in the latter case separate those with obstructive or chronic parenchymal liver disease. It should also allow identification of important complications such as encephalopathy, ascites and portal hypertension. Identification of these main features or complications of liver disease by the clinical evaluation leads to a logical plan of investigation and prompt diagnosis and management of the liver disease.

Vitamin D deficiency and otosclerosis

A prospective study of 47 patients with otosclerosis was undertaken to investigate the possible etiologic role of vitamin D undernutrition. The population comprised 27 women and 20 men, with a mean age of 46.4 years (range 21 to 79). The disease was bilateral in 43 patients, and cochlear involvement was present in 84.4%. The mean duration of symptoms was 17.1 years. Vitamin D status was evaluated by measuring the plasma 25-hydroxy vitamin D3 (25-OHD), which is the main storage metabolite. Abnormally low 25-OHD levels were found in 10 patients (21.7%) and borderline low levels in another two. Raised serum alkaline phosphatase levels were present in 32.6%, calcium in 6.5%, and inorganic phosphate in 4.3%. Calcium and vitamin D replacement therapy resulted in significant hearing improvement in 3 of 16 patients; these data support a causal correlation. Vitamin D deficiency is probably a factor in the etiology of some cases of otosclerosis and is important, since the deafness resulting from cochlear involvement may be reversible.

Vitamin D deficiency--a new cause of cochlear deafness

Ten patients are reported with bilateral cochlear deafness which was associated with vitamin D deficiency. The features of these cases are discussed following an overview of the clinical aspects and diagnosis of vitamin D deficiency. The most likely pathogenesis is localized demineralization of the cochlea resulting in secondary morphological changes. Replacement therapy resulted in unilateral hearing improvement in two of the four patients in whom the response to treatment could be assessed. This suggests a previously unrecognized causal correlation between vitamin D deficiency and cochlear deafness. Impaired vitamin D activity may be important in the aetiology of otosclerosis, presbyacusis and the deafness associated with chronic renal failure. Vitamin D deficiency should be considered in the differential diagnosis of unexplained bilateral cochlear deafness. It is important, as this 'new' metabolic type of sensorineural deafness may be reversible, and may also lead to the diagnosis of early osteomalacia before more serious generalized skeletal symptoms can occur.