SHM Converge Scientific Abstract ePoster Gallery-A Bone to Pick With Vitamin A

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This case describes a 54-year-old man with alcoholic cirrhosis who presented with a nonpainful facial rash and was found to have severe hypercalcemia and acute kidney injury. His main symptom was cosmetic concern about the rash, which dermatology diagnosed as seborrheic dermatitis and possibly worsened by increased skin sensitivity from vitamin A toxicity.<br /><br />He had been taking an over-the-counter vitamin A supplement for 2–3 months at 9,000 mcg/day, believing it matched his prior prescribed dose. In fact, this was about three times higher than intended. His evaluation for common causes of hypercalcemia was negative, including malignancy, thyroid disease, and monoclonal gammopathy. Labs showed calcium 15.6 mg/dL, suppressed PTH, elevated PTHrP, low 1,25-dihydroxy vitamin D, and a markedly elevated retinyl palmitate level, supporting vitamin A excess as the cause.<br /><br />Vitamin A toxicity is a rare but important cause of hypercalcemia. It is thought to increase bone resorption by stimulating osteoclast activity and inhibiting osteoblast formation. The elevated PTHrP was likely related to reduced clearance from kidney injury rather than cancer. Unlike hypercalcemia of malignancy, his calcium improved with supportive care alone. He was treated with IV fluids and one dose of calcitonin; bisphosphonates were avoided because of renal dysfunction.<br /><br />The key lesson is that in patients with cirrhosis, who are often advised to take vitamin supplements, clinicians should carefully review over-the-counter products and consider vitamin A toxicity in the differential diagnosis of hypercalcemia.

Asset Subtitle

Catherine E. Firestein

Meta Tag

Author List Catherine E. Firestein, Charles Hammond, Farnoosh Vahedi

Category Clinical Vignettes

Concept Vitamin A Toxicity

Concept Hypercalcemia

Concept Osteoclast Activation

Concept Osteoblastic Bone Formation

Concept Dosing Error

Distinguished Non-Finalist

Presenter Organization UC San Diego Health

Presenting Author Catherine E. Firestein

Track Adult

Keywords

vitamin A toxicity

hypercalcemia

acute kidney injury

alcoholic cirrhosis

seborrheic dermatitis

retinyl palmitate

PTHrP elevation

bone resorption

over-the-counter supplement

calcitonin treatment

Vitamin A Toxicity

Hypercalcemia

Osteoclast Activation

Osteoblastic Bone Formation

Dosing Error