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Acute renal failure, anorexia, pruritus and asthenia in a patient with cystic fibrosis: a vitamin pill a day doesn’t always keep the doctor away.
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Acute renal failure, anorexia, pruritus and asthenia in a patient with cystic fibrosis: a vitamin pill a day doesn’t always keep the doctor away.
A 37-year-old male patient with delF508 homozygous cystic fibrosis was admitted for the development of anorexia, fatigue, diffuse tingling, polyuria, atypical chest pain and general malaise over one week. Complications of his disease included bronchiectasis chronically infected with Pseudomonas aeruginosa, an endocrine and exocrine pancreatic insufficiency requiring supplementation with insulin, pancreatic enzymes and liposoluble vitamins. The latter medication consisted of a handmade preparation compounded by his pharmacist of vitamin A/D/E/K (containing in total respectively 10000 IU, 8000 IU, 400IU and 10mg) taken in 4 times daily. He had renewed his prescription for this medication 3 weeks before his presentation. Clinical examination was unremarkable including the absence of cutaneous rash. Serum creatinine was elevated more than 3 times of the baseline value (2.78mg/dL and GFR 28mL/min for a baseline of 0.8mg/dL and GFR 115mL/min), corresponding to an acute kidney injury Kidney Disease Improving Global Outcome grade 3. Serum calcium was highly superior to normal values, with measurement of concentrations of 3.65 mmol/L (normal values 2.15-2.5 mmol/L). The electrocardiogram showed a normal sinusal rhythm, with ST segment elevations of 3 mm in the anterior leads and shortening of the QTc at 348msec. Chest radiography was unchanged when compared with previous one. Serum levels of 25-OH vitamin D proved to be highly toxic at 692ng/mL (normal values 30-60ng/mL) with an adapted low value of parathyroid hormone (7pg/mL, normal values 15-80pg/mL). The patient denied any intentional intoxication and an analysis of the composition of the A/D/E/K pills was performed. This revealed highly toxic levels of 25-OH vitamin D in his medication, resulting in a daily intake of 430000 IU. The levels of the other vitamins were within the prescribed range and subsequent serum measurement could not reveal toxic levels. The patient was treated with intravenous fluid therapy, furosemide and received salmon calcitonin. He was also administrated pamidronate on the second day and received daily oral methylprednisone. After initiation of treatment, the serum calcium concentrations and creatinine quickly returned to normal values, with simultaneous normalization of the ECG and disappearance of the aforementioned symptoms. We concluded to a hypercalcemia with cardiac and renal toxicity due to an unintentional vitamin D intoxication. We feel that this case is of particular interest because it reminds us the danger of handmade drugs. Caring for cystic fibrosis patients remained a challenge in such cases even in high income countries such as Belgium, where one would expect stringent standards of care regarding medicinal preparations.
Plante-Bordeneuve, Thomas ; Lebecque, Patrick ; Henri, Laurence ; Bastin, Pierre ; Gruson, Damien ; et. al. Acute renal failure, anorexia, pruritus and asthenia in a patient with cystic fibrosis: a vitamin pill a day doesn’t always keep the doctor away..Société Belge de pneumologie (Belgium, du 02/12/2017 au 03/12/2017).