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1.
How Much Vitamin D is Too Much? A Case Report and Review of the Literature.
De Vincentis, S, Russo, A, Milazzo, M, Lonardo, A, De Santis, MC, Rochira, V, Simoni, M, Madeo, B
Endocrine, metabolic & immune disorders drug targets. 2021;(9):1653-1659
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Abstract
BACKGROUND The beneficial effects of vitamin D, together with the high prevalence of vitamin D deficiency, have led to an expanding use of vitamin D analogues. While inappropriate consumption is a recognized cause of harm, the determination of doses at which vitamin D becomes toxic remains elusive. CASE PRESENTATION A 56-year woman was admitted to our Hospital following a 3-week history of nausea, vomiting, and muscle weakness. The patient had been assuming a very high dose of cholecalciferol for 20 months (cumulative 78,000,000UI, mean daily 130,000UI), as indicated by a non-- conventional protocol for multiple sclerosis. Before starting vitamin D integration, serum calcium and phosphorus levels were normal, while 25OH-vitamin D levels were very low (12.25 nmol/L). On admission, hypercalcemia (3.23 mmol/L) and acute kidney injury (eGFR 20 mL/min) were detected, associated with high concentrations of 25OH-vitamin D (920 nmol/L), confirming the suspicion of vitamin D intoxication. Vitamin D integration was stopped, and in a week, hypercalcemia normalized. It took about 6 months for renal function and 18 months for vitamin D values to go back to normal. CONCLUSION This case confirms that vitamin D intoxication is possible, albeit with a high dose. The doses used in clinical practice are far lower than these and, therefore, intoxication rarely occurs even in those individuals whose baseline vitamin D serum levels have never been assessed. Repeated measurements of vitamin D are not necessary for patients under standard integrative therapy. However, patients and clinicians should be aware of the potential dangers of vitamin D overdose.
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Unusual Presentation of Denys-Drash Syndrome in a Girl with Undisclosed Consumption of Biotin.
Bizzarri, C, Antonella Giannone, G, Gervasoni, J, Benedetti, S, Albanese, F, Dello Strologo, L, Guzzo, I, Mucciolo, M, Diomedi Camassei, F, Emma, F, et al
Journal of clinical research in pediatric endocrinology. 2021;(3):347-352
Abstract
We describe a 46,XX girl with Denys-Drash syndrome, showing both kidney disease and genital abnormalities, in whom a misdiagnosis of hyperandrogenism was made. A 15 year-old girl was affected by neonatal nephrotic syndrome, progressing to end stage kidney failure. Hair loss and voice deepening were noted during puberty. Pelvic ultrasound and magnetic resonance imaging showed utero-tubaric agenesis, vaginal atresia and urogenital sinus, with inguinal gonads. Gonadotrophin and estradiol levels were normal, but testosterone was increased up to 285 ng/dL at Tanner stage 3. She underwent prophylactic gonadectomy. Histopathology reported fibrotic ovarian cortex containing numerous follicles in different maturation stages and rudimental remnants of Fallopian tubes. No features of gonadoblastoma were detected. Unexpectedly, testosterone levels were elevated four months after gonadectomy (157 ng/dL). Recent medical history revealed chronic daily comsumption of high dose biotin, as a therapeutic support for hair loss. Laboratory immunoassay instruments used streptavidin-biotin interaction to detect hormones and, in competitive immunoassays, high concentrations of biotin can result in false high results. Total testosterone, measured using liquid chromatography tandem mass spectrometry, was within reference intervals. Similar testosterone levels were detected on repeat immunoassay two weeks after biotin uptake interruption. Discordance between clinical presentation and biochemical results in patients taking biotin, should raise the suspicion of erroneous results. Improved communication among patients, health care providers, and laboratory professionals is required concerning the likelihood of biotin interference with immunoassays.
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Cytotoxic Lesions of the Corpus Callosum Caused by Thermogenic Dietary Supplements.
Galnares-Olalde, JA, Vázquez-Mézquita, AJ, Gómez-Garza, G, Reyes-Vázquez, D, Higuera-Ortiz, V, Alegría-Loyola, MA, Mendez-Dominguez, A
AJNR. American journal of neuroradiology. 2019;(8):1304-1308
Abstract
Consumption of over-the-counter dietary supplements to reduce body weight is common among the population. Thermogenics are herbal combinations that claim to produce a fat-burning process through an increase in the cellular metabolic rate and greater cellular energy consumption, having a high risk for patients developing toxic leukoencephalopathy. We present a series of 6 patients with acute neurologic symptoms and MR imaging showing restricted diffusion and decreased apparent diffusion coefficient values (mean value, 400 mm2/s × 10-6) in the entire corpus callosum compatible with a cytotoxic lesion of the corpus callosum. Although patients responded favorably to the product discontinuation with rapid recovery of neurologic symptoms, there was a more prolonged resolution on imaging alterations. Because of the widespread availability and unregulated nature of thermogenic dietary supplements, physicians must be aware of the clinical and radiologic characteristics of these potential complications of their use.
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4.
Acute Liver Failure Induced by Carthamus tinctorius Oil: Case Reports and Literature Review.
de Ataide, EC, Reges Perales, S, de Oliveira Peres, MA, Bastos Eloy da Costa, L, Quarella, F, Valerini, FG, Chueiri Neto, F, Silveira Bello Stucchi, R, de Fátima Santana Ferreira Boin, I
Transplantation proceedings. 2018;(2):476-477
Abstract
BACKGROUND Acute liver failure (ALF) is a clinical syndrome that results from the abrupt loss of liver function in a patient without previous liver disease. The most frequent causes are viral hepatitis, drug induced, and autoimmune disease, but in 20% of cases no cause is identified. Carthamus tinctorius (safflower) oil is used as a dietary supplement for weight loss and antioxidant. There are 4 cases described in the literature of ALF induced by the use of this substance. The objective of this study was to report 3 cases of ALF treated at the Clinical Hospital of the State University of Campinas that suggest the use of C tinctorius oil as a probable etiologic factor. CASE REPORTS The 3 patients had a diagnosis of ALF according to the King's College criteria. All had a history of ingestion of this oil for weight loss. During etiologic evaluation, viral hepatitis, autoimmune diseases, or any other drug cause were excluded, thus pointing to C tinctorius oil as the triggering factor. All 3 patients underwent liver transplantation: 2 had good postoperative evolution, and 1 died 12 days after the procedure. CONCLUSIONS Two cases are described in which the hepatic insufficiency induced by C tinctorius oil was successfully treated through liver transplantation. This highlights the risk of misuse of this substance for weight loss.
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5.
Heart Toxicity Related to Herbs and Dietary Supplements: Online Table of Case Reports. Part 4 of 5.
Brown, AC
Journal of dietary supplements. 2018;(4):516-555
Abstract
BACKGROUND The purpose of this review was to create an online research summary table of heart toxicity case reports related to dietary supplements (DS; includes herbs). METHODS Documented PubMed case reports of DS appearing to contribute to heart-related problems were used to create a "Toxic Table" that summarized the research (1966 to April, 2016, and cross-referencing). Keywords included "herb," "dietary supplement," and cardiac terms. Case reports were excluded if they were herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm (e.g. suicide), excess dose (except vitamins/minerals), drugs or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. The spectrum of heart toxicities included hypertension, hypotension, hypokalemia, bradycardia, tachycardia, arrhythmia, ventricular fibrillation, heart attack, cardiac arrest, heart failure, and death. RESULTS Heart related problems were associated with approximately seven herbs: Four traditional Chinese medicine herbs - Don quai (Angelica sinensis), Jin bu huan (Lycopodium serratum), Thundergod vine or lei gong teng (Tripterygium wilfordii Hook F), and Ting kung teng (Erycibe henryi prain); one an Ayruvedic herb - Aswagandha, (Withania somnifera); and two North American herbs - blue cohosh (Caulophyllum thalictroides), and Yohimbe (Pausinystalia johimbe). Aconitum and Ephedra species are no longer sold in the United States. The DS included, but are not limited to five DS - bitter orange, caffeine, certain energy drinks, nitric oxide products, and a calming product. Six additional DS are no longer sold. Licorice was the food related to heart problems. CONCLUSION The online "Toxic Table" forewarns clinicians, consumers and the DS industry by listing DS with case reports related to heart toxicity. It may also contribute to Phase IV post marketing surveillance to diminish adverse events that Government officials use to regulate DS.
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Aloe vera-induced acute liver injury: A case report and literature review.
Parlati, L, Voican, CS, Perlemuter, K, Perlemuter, G
Clinics and research in hepatology and gastroenterology. 2017;(4):e39-e42
Abstract
Recent data suggest that herbal and dietary supplements are the second most common cause of liver injury. We herein report a case of acute liver injury in a 68-year old female caused by ingestion of Aloe vera. Upon discontinuation of the oral Aloe vera, liver function tests (LFT) returned to normal levels. Thus, it is crucial to consider the use of herbal products as causative agents of acute liver injury.
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7.
[Hypervitaminosis D due to a dietary supplement].
Zigenhorn, M, Westerman, EM, Rietveld, AP
Nederlands tijdschrift voor geneeskunde. 2016;:A9360
Abstract
In the Netherlands, over-the-counter dietary supplements are controlled by the NVWA (Netherlands Food and Consumer Product Safety Authority). Nevertheless, health problems may ensue from the use of these freely available supplements. We describe the case of a 39-year-old woman with a four-week history of headaches, nausea, reduced appetite and weight loss. Laboratory results showed severe hypercalcemia and impaired kidney function. An isolated increased vitamin D level was shown to be the cause. Although initial drug-taking history was negative, it appeared our patient had consumed a concentrated vitamin D supplement, supplied by a naturopath. The vitamin D concentration of the contents of this specific flacon proved to be 78 times higher than stated on the label. Consumers must be aware of the potential health risks posed by over-the-counter dietary supplements. We appeal to GPs, medical specialists and pharmacists to report these kinds of intoxications, allowing relevant authorities to subject the associated companies to adequate control measures.
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8.
Iatrogenic vitamin D toxicity in an infant--a case report and review of literature.
Ketha, H, Wadams, H, Lteif, A, Singh, RJ
The Journal of steroid biochemistry and molecular biology. 2015;:14-8
Abstract
Public concern over vitamin D deficiency has led to widespread use of over the counter (OTC) vitamin D (-D3 or -D2) supplements, containing up to 10,000 IU/unit dose (400 IU=10μg). Overzealous use of such supplements can cause hypercalcemia due to vitamin D toxicity. Infants are particularly vulnerable to toxicity associated with vitamin D overdose. OTC supplements are not subject to stringent quality control regulations from FDA and high degree of variability in vitamin D content in OTC pills has been demonstrated. Other etiologies of vitamin D induced hypercalcemia include hyperparathyroidism, granulomatous malignancies like sarcoidosis and mutations in the CYP24A1 gene. The differential diagnosis of hypercalcemia should include iatrogenic and genetic etiologies. C24-hydroxylation and C3-epimerization are two important biochemical pathways via which 25-hydroxyvitamin D3 (25(OH)D3) is converted to its metabolites, 24,25-dihydroxyvitamin D3 (24,25(OH)2D3) or its C3 epimer, 3-epi-25-OH-D3 respectively. Mutations in the CYP24A1 gene cause reduced serum 24,25(OH)2D3 to 25(OH)D3 ratio (<0.02), elevated serum 1,25-dihydroxyvitamin D (1,25(OH)2D3), hypercalcemia, hypercalciuria and nephrolithiasis. Studies in infants have shown that 3-epi-25(OH)D3 can contribute 9-61.1% of the total 25(OH)D3. Therefore, measurements of parathyroid hormone (PTH) and vitamin D metabolites 25(OH)D3, 1,25(OH)2D3, 3-epi-25(OH)D3 and 24,25(OH)2D3 are useful to investigate whether the underlying cause of vitamin D toxicity is iatrogenic versus genetic. Here we report a case of vitamin D3 associated toxicity in a 4-month-old female who was exclusively breast-fed and received an oral liquid vitamin D3 supplement at a dose significantly higher than recommended on the label. The vitamin D3 content of the supplement was threefold higher (6000 IU of D/drop) than listed on the label (2000 IU). Due to overdosing and higher vitamin D3 content, the infant received ∼50,000 IU/day for two months resulting in severe hypercalcemia, hypercalciuria and nephrocalcinosis. We also review the relevant literature on vitamin D3 toxicity in this report.
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9.
Unexplained hypoxia in an in-flight emergency.
Coffey, DD
Aviation, space, and environmental medicine. 2014;(6):662-7
Abstract
BACKGROUND The use of over-the-counter medications and nutritional supplements is prohibited while flying without approval from an aeromedical professional. Despite prohibition, the use of nutritional supplements is common in aircrew due to the perception that these supplements are harmless; in reality, the use of nutritional supplements may be more dangerous than the use of traditional medications. Multiple case reports of adverse neurologic and cardiovascular events associated with the use of specific supplements led the FDA to ban ephedra in 2004 and DMAA in 2012, both marketed as "natural stimulants." These incidents are sobering reminders of the lack of safety data on commonly marketed nutritional supplements. There are few, if any, case reports or clinical trials addressing the safety of common nutritional supplements in flight. CASE REPORT This is a case of an aircrew member who experienced hypoxia during an in-flight emergency. He underwent thorough medical evaluation to determine the cause of his hypoxic event and ultimately admitted to the use of a pre-workout supplement: C4 Extreme. He was exposed to simulated altitude both on and off of the supplement and was found to have an improved tolerance to a hypoxic environment after discontinuation. DISCUSSION While not conclusive, the data suggests that the use of C4 Extreme may be implicated in this aircrewman's increased susceptibility to hypoxia. A randomized controlled trial would be required to determine if this is a patient-specific response or if this is a normal physiologic response to the use of this and similar supplements.
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Herbal medications and plastic surgery: a hidden danger.
Mohan, A, Lahiri, A
Aesthetic plastic surgery. 2014;(2):479-81
Abstract
Herbal medicine is a multibillion-pound industry, and surveys suggest that ~10% of the UK population uses herbal supplements concurrently with prescription medications. Patients and health care practitioners are often unaware of the adverse side effects of herbal medicines. In addition, because many of these herbal supplements are available over the counter, many patients do not disclose these when listing medications to health care providers. A 39-year-old nurse underwent an abdominoplasty with rectus sheath plication after weight loss surgery. Postoperatively, she experienced persistent drain output, and after discharge, a seroma developed requiring repeated drainage in the clinic. After scar revision 10 months later, the woman bled postoperatively, requiring suturing. Again, a seroma developed, requiring repeated drainage. It was discovered that the patient had been taking a herbal menopause supplement containing ingredients known to have anticoagulant effects. Complementary medicine is rarely taught in UK medical schools and generally not practiced in UK hospitals. Many supplements are known to have anticoagulant, cardiovascular, and sedative effects. Worryingly, questions about herbal medicines are not routinely asked in clinics, and patients do not often volunteer such information. With the number and awareness of complementary medications increasing, their usage among the population is likely to increase. The authors recommend specific questioning about the use of complementary medications and consideration of ceasing such medications before surgery. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .