Pamidronate treatment of hypercalcemia caused by vitamin D toxicity

We present a 16 month-old previously healthy boy with refractory hypercalcemia due to an overdose of an over-the-counter vitamin supplement. The patient presented to the emergency department with a few weeks' history of irritability, constipation and intermittent vomiting. His serum calcium was found to be 18 mg/dl. He was first treated with intravenous fluids, furosemide and glucocorticoids without significant improvement, but became eucalcemic within 24 hours after receiving a single dose of pamidronate. This case highlights the potential danger of high dose vitamin supplements in children, and the salutary effects of treatment with bisphosphonate.     

Severe hypercalcemia due to vitamin D intoxication]

We report on a case of severe hypercalcemia due to vitamin D intoxication in a 4-month-old infant, CASE REPORT: A 4-month-old boy was admitted for anorexia, weakness, hypotonia, constipation and lethargy. Initial physical examination evidenced a severe axial hypotonia, signs of moderate intracellular dehydration, polyuria and leucocyturia. Hemodynamic parameters were normal. The infant's origin was Turkish. Basic blood chemistry showed a high serum calcium concentration of 4.28 and 4.55 mmol/l on a second control. The EKG showed a short QTc interval calculated at 0.34 s. Due to worsening neurological condition, the infant was referred to the pediatric intensive care unit. Because of the association of neurological impairment, EKG abnormality and high serum calcium level, haemodialysis was performed. Treatment included hyperhydration, high doses of intravenous of loop diuretics and sodium pamidronate infusion. Hormonal, radiological, abdominal and cardiac investigations combined with a new parental interview led to the diagnosis of vitamin D intoxication due to excessive daily administration. We were unable to determine the exact total amount because of the language barrier. Clinical outcome was marked by nephrocalcinosis without renal function impairment, iliac venous thrombosis secondary to the dialysis catheter and a full neurological recovery without sequelae after 3 months. DISCUSSION: Fear of rickets, especially in Turkish families residing in France, can lead some parents to administer massive daily quantities of vitamin D. This practice is facilitated by the possibility of purchasing high dosage forms of vitamin D via the Internet. When faced with an infant presenting with digestive disorders such as vomiting and constipation, associated with neurological troubles (lethargy, hypotonia) and hypercalcemia, vitamin D intoxication should be considered after tumoral, hormonal or malformative (Williams-Beuren syndrome) causes have been eliminated. Combined with hyperhydration and loop diuretics, biphosphonate infusion often allows to control hypercalcemia. Nephrocalcinosis seems correlated to chronic administration while cardiovascular disorders are more likely associated with massive acute vitamin D administration, severe dysrhythmia being rare in children in this context.     

Severe acute tonsillitis caused by Rothia dentocariosa in a healthy child

A 4-year-old Japanese girl developed a sore throat and high fever. Her tonsils were enlarged, red and covered with a thick white membrane. There was marked leukocytosis (26,600 leukocytes per mm) and elevated C-reactive protein levels (23.3 mg/dL). Rothia dentocariosa was recovered from the throat swab; many Gram-positive cocci were observed in the smear from the pseudomembrane covering the tonsil.     

Status epilepticus caused by accidental isoniazid poisoning

A case of acute poisoning in a 32 months old child, with generalised and uncontrollable seizures is reported. Pyridoxine IV is efficacely used in such poisoning.     

Severe hypercalcemia of an infant due to vitamin D toxicity associated with hypercholesterolemia

We report an 11 month-old infant with severe hypercalcemia associated with hyperlipidemia following bolus vitamin D administration. At the time of admission, serum concentration of calcium was 5.5 mmol/l (22 mg/dl); total cholesterol, high density lipoprotein cholesterol (HDL-C), very low density lipoprotein (VLDL), low density lipoprotein cholesterol (LDL-C), and triglyceride levels were respectively: 6.37 mmol/l (246 mg/dl), 0.77 mmol/l (30 mg/dl), 1.37 mmol/l (54 mg/dl), 4.1 mmol/l (162 mg/dl), 3 mmol/l (271 mg/dl). Physical examination revealed dehydration and irritability that was inappropriately mild according to the serum calcium level. On the 16th day of therapy that consisted of intravenous fluids with furosemide (sodium diuresis), steroid, calcitonin, magnesium sulfate, and phosphorus, serum calcium level declined below 3 mmol/l (12 mg/dl). The hyperlipidemia resolved gradually with a concomitant decline in serum calcium. This report is interesting in that hypercalcemia was associated with transient hyperlipidemia that disappeared with normocalcemia, which might suggest protection against hypercalcemic symptoms.     

Life-threatening hypercalcemia complicated by pancreatitis in a child with acute lymphoblastic leukemia

The authors describe a 9-year-old girl with precursor-B acute lymphoblastic leukemia (ALL) who presented with dehydration and severe hypercalcemia. She had received oral vitamin D and calcium supplementation for 4 days, the last dose 48 hours prior to admission, and required pediatric intensive care unit (PICU) hospitalization for management of the hypercalcemia and safe initiation of induction chemotherapy. Her clinical course was complicated by pancreatitis, disseminated intravascular coagulation, pleural effusion, and focal seizures. Although the exact mechanism of hypercalcemia was not elucidated, it was likely related to the underlying ALL, without dismissing the prior vitamin D and calcium supplementation as a possible contributing factor. The hypercalcemia resolved with specific antileukemic therapy along with supportive care and administration of calcitonin. Hypercalcemia is an uncommon metabolic abnormality in children with ALL, but it can be life-threatening. Children with ALL should be referred to tertiary-care institutions with PICU and subspecialty support because serious metabolic and other complications can occur before or after the administration of chemotherapy.     

误服大量味精致抽搐一例

患儿，男，5个月。因反复抽搐3d于2006年2月20日来诊。患儿1周前其祖母误将味精作为白糖加入奶粉中给予冲服，每次约2—3汤匙，每天4—5次，连服3d。第4天起患儿出现抽搐，发作时双眼上翻、双手握拳、四肢抽动，神志尚清，每次发作1—2min而自行缓解，每天发作2～3次。发作间歇期精神活动正常。发病以来，食欲较差，无恶心、呕吐，无发热，无尖叫，大小便正常。患儿系第1胎足月顺产儿，出生时无窒息史，家族中无癫痫病患者。体检：T36℃，P120次／min，R32次／min，BP85／60mmHg（1mmHg=0．133kPa），W6kg。神志清，精神尚好。皮肤巩膜正常。浅表淋巴结不大。双侧瞳孔等圆等大，直径约2mm，对光反射灵敏。颈软。心肺无阳性征。肝脾肋下未触及。四肢肌力、肌张力正常，生理反射正常，未引出病理神经反射。[第一段]     

Hemodialysis in a child with accidental digitalis poisoning (author's transl)]

A case of an accidental digitalis intoxication in a two year old child is reported. Early Hemodialysis effectively reduced the high plasma levels of digoxin and replaced other therapeutical procedures.     

Severe hypercalcemia as a harbinger of acute lymphoblastic leukemia

CASE: An 8-year-old girl presented to the emergency department with a history of nausea, vomiting, abdominal pain, tiredness, and weight loss of 18 lb over 3 weeks. The only significant examination finding was moderate dehydration. She was found to have severe hypercalcemia (serum calcium, 20 mg/dL). The complete blood count was normal. She was treated successfully for hypercalcemia with hyperhydration, furosemide, calcitonin, and pamidronate. A few days later, she developed pancytopenia when her bone marrow biopsy specimen established the diagnosis of acute lymphoblastic leukemia. CONCLUSIONS: Hypercalcemia presents with nonspecific symptoms of nausea, vomiting, pain in the abdomen, constipation, and tiredness. It can be a harbinger of acute lymphoblastic leukemia. Normal complete blood cell count at presentation does not exclude the diagnosis of leukemia.     

Severe potassium dichromate poisoning after accidental nasal introduction]

BACKGROUND: Nasal foreign body (NFB) is a common situation in pediatrics. Poisoning is a rare complication of NFB insertion. We report a case of acute potassium dichromate poisoning secondary to NFB insertion. CASE REPORT: Six days after insertion of a NFB, progressive occurrence of diarrhea, vomiting, nasal obstruction, acute renal failure, pancreatitis, hepatitis and drowsiness justified hospitalization of a 3-year-old girl in the pediatric intensive care unit. Acute potassium dichromate poisoning was confirmed by high plasma chromium level and by the spectrophotometric analysis of the crystal. Recovery was satisfactory with supportive treatment. An official survey allowed to discover that the crystal was freely sold and that its toxicity was unknown by dealers, while no information was given to the customers. CONCLUSION: Transmucosal absorption of toxics is an unusual severe potential hazard that should be evoked to allow a rapid management. After the discovery and withdrawal of a NFB, occurrence of systemic symptoms, even trivial, must make one suspect a poisoning. In this circumstance, analysis of the foreign body should be done, associated with toxicologic dosages. This case report illustrates that potassium dichromate poisoning is a severe medical condition and that its clinical presentation assume a large widespread of symptoms due to multiple organ involvement.     

Acute vitamin D intoxication in a child

We present the unique case of a previously healthy, 2-year-old boy with resistant hypercalcemia and hypertension resulting from an unintentional overdose with an imported vitamin D supplement. The patient presented initially to the emergency department with colic and constipation and was discharged after a benign physical examination. The symptoms persisted and, on the second visit, the patient was found to have a serum calcium level of 14.4 mg/dL. Despite therapy with intravenously administered 5% dextrose solution at one-half normal strength, furosemide, calcitonin, and hydrocortisone, the calcium concentration increased to 15.0 mg/dL on the second hospital day and did not decrease until the fourth hospital day, when it fell to 13.9 mg/dL. The vitamin D concentration peaked at 470 ng/mL on hospital day 3. With additional questioning, the mother revealed that she had been giving her son a daily dose of 1 ampule of Raquiferol, an imported vitamin D supplement, instead of the recommended 2 drops per day. Each ampule contained 600,000 IU of vitamin D; therefore, the boy received a total of 2,400,000 IU over 4 days. The patient's hypercalcemia persisted for 14 days and was complicated by persistent hypertension. No renal, cardiac, or neurologic complications were noted. At discharge, the vitamin D concentration was still elevated at 389 ng/mL and the total calcium level had decreased to 11 mg/dL. The boy made a complete clinical recovery. This case highlights the need for caution when using imported and/or unregulated medicines, as well as the dangers of parental dosing errors.     

Renal cell carcinoma in a child presented as bilateral femur neck fractures caused by severe vitamin D deficiency

An Ethiopian girl 14 years and 11 months of age presented with bilateral transcervical hip fractures. Workup revealed severe vitamins D and C deficiencies with secondary hyperparathyroidism. Imaging studies showed bilateral radiolucent metaphyseal bands with multiple lytic lesions in long bones. A mass in the right flank was found to be renal cell carcinoma (RCC). Currently, 9 months postsurgery and supplemental therapy, the patient is fully ambulatory and free of pain. This first report of asymptomatic RCC in severely vitamin D deficient child highlights the relation of RCC to vitamin D deficiency and emphasizes the importance of careful evaluation of these children.     

Severe acute pancreatitis in a child with phenylketonuria

We report for the first time severe acute pancreatitis in a child treated for phenylketonuria (PKU) discovered on neonatal screening. This 2-year-old boy was first hospitalized for bilious vomiting and moderate back pain. Laboratory values included a lipase level of 1.142 U/L, a phenylalanine level of 10 mg/dL, and computed tomography revealed Balthazar grade E pancreatitis. Continuous enteral feeding was started on the 3rd day after admission. We observed clinical and biological improvement. Etiologic investigations for pancreatitis returned negative. Despite the severity of the pancreatitis, we did not observe decompensation of the metabolic disease. Specific nutritional management was necessary.     

Non accidental repeated lithium poisoning in a child: The role of hair analysis

Non accidental intoxication due to child abuse is rare and its frequency is likely underestimated because it is difficult to diagnose. Here, we report a case of voluntary repeated exposure to lithium in an infant, for whom the clinical manifestations were convulsions. Toxicological analysis was very helpful for documenting lithium exposure during the assumed period of time. Interpreting the results of hair analysis, a simple and minimally invasive examination, is tricky at this age, but it can facilitate the differentiation of acute versus chronic exposure. Although infrequent and underestimated, lithium should be considered as a cause of intoxication in a previously healthy child with acute seizure.