Vol 39 # 2 June 2007 - Kma.org.kw

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June 2007KUWAIT MEDICAL JOURNAL 155Table 1b: biochemical values post-treatment with high dose of vitD.Patient Calcium Phosphate Alkaline Urinary PTH25 (OH)DNo. (mmol/l) (mmol/l) phospha- Calcium phosphate (pmol/l) leveltase(mmol/l) (mmol/24hr) (nmol/l)1 2.51 1.32 273 7.1 2.68 4.7 1022 2.29 1.71 126 0.9 4.7 1.2 1203 2.36 1.22 72 3.49 10.1 5.9 784 2.34 1.57 144 6.2 9.4 4.4 1125 2.17 1.01 224 2.33 8.43 10.1 1556 2.18 0.92 119 3.32 12.3 5.5 2227 2.32 1.67 34 1.04 21.4 2.8 808 2.04 1.32 85 4.12 4.5 16.3 969 2.4 1.39 469 3.66 16.3 19.1 10910 2.6 1.22 122 2.46 7.92 17.4 6511 2.26 1.77 272 2.8 9.4 6.1 19412 2.4 1.44 360 2.61 8.8 12.6 9013 2.35 1.34 215 1.99 1.01 4.61 5014 2.4 1.47 68 3.21 5.96 2.33 14115 2.32 1.35 166 1.86 6.73 5.5 —-16 2.31 1.19 93 1.02 8.7 4.93 7817 2.09 1.12 219 1.82 0.27 6.22 8918 2.34 1.35 122 2.0 5.4 3.8 —-19 2.3 1.41 96 0.98 4.2 2.15 3920 2.61 2.44 112 3.21 4.47 5.2 12021 2.4 1.33 147 — — —- 7522 2.2 1.04 401 2.31 6.11 7.01 8123 2.19 1.02 213 1.97 9.01 5.7 6524 2.41 1.23 89 3.12 .95 4.3 91— = data not availablehr (normal = 13-42), serum PTH = 38.68 ± 23.43,10.85 ± 4.49 pmol/l (normal = 0.7-5.6), 25(OH)D =8.10 ± 8.05 nmol/l (normal = 23-113) and skeletal X-ray showed pseudofractures (looser’s zones, whichare nearly pathognomonic features of rickets andosteomalacia) in some of our patient andpathological fracture in one patient. Bonedensitometry scan showed osteopenia andosteoporosis in most patients and the mean T-Scorewas - 2.086 ± 0.91. All symptoms and signsimproved dramatically during treatment with highdose of vitamin D and calcium. Health educationthat helped in greater exposure to sunlight (at least10 minutes daily) and an increase in theconsumption of dairy products to obtain approximately1 g of calcium daily had an important role inthe management. There were no re p o r t e dsymptoms or biochemical finding of hyperc a l c e m i a .DISCUSSIONIn our study, we found that patients in a sunnyclimate like Kuwait may still present withosteomalacia due to vitamin D deficiency as a resultof insufficient sunlight exposure and inadequatedairy product intake. Almost all our patient (96%)consumed less than 1,000 mg of calcium per week,while the daily requirement is about 1,200 mg. Alsosome of our patients were from the lowsocioeconomic status and lived in houses wherelittle if any sunlight was allowed to enter. Theywere also ignorant about the value of vitamin Dand calcium for the process of bone mineralization.They were eating very minimal amounts of calciumcontaining products (because they did not like milkand/or diary products) and they were wearingtraditional or religious clothing that covered all thebody except the eyes (long dress hejab, niquab,abaya, gloves and socks). This resulted ininadequate exposure to sunlight re q u i red forvitamin D synthesis. These overclothing styleamong women as young as eight years old maylead to vitamin D deficiency. This also explains whyall our patients were female since this clothinghabit is exclusive to women. This is in agreementwith a previous study which concluded thatvitamin D deficiency in the Middle East was due toclothing habits [5] . It is also known from previousstudies that UV radiation passes through glass andmost plastics [ 1 ] but not through clothing andsunscreen [6,7] .The prevalence of osteomalacia due to vitaminD deficiency is unknown in Kuwait and anepidemiological study is required.Almost all of our patients presented with typicalnon-specific symptoms of osteomalacia such aslethargy, proximal muscle weakness, and diffusebone pain. We noticed that proximal muscleweakness is so prominent among our patients thatit can be used as a good indicator of improvementfollowed by other symptoms like diffuse bone painand the feeling of lethargy. On presentation onepatient had symptoms of hypocalcemia (numbnessand tingling sensation around the mouth andc o r rected serum calcium found to be low (1.8mmol/l) and another had a pathological fracturedue to severe osteoporosis which is a knowncomplication of severe osteomalacia.The clinical diagnosis of osteomalacia is basedon the findings of low levels of 25(OH)D, serumcalcium, serum phosphate, urinary calcium andphosphate and increased levels of alkalinephosphatase, PTH. These abnormal biochemicalfindings result from vitamin D deficiency whichresults in decreased intestinal absorption of calciumand phosphate that consequently lead to secondaryh y p e r p a r a t h y roidism. The cornerstone in thediagnosis of osteomalacia is the demonstration of areduction in the mineral apposition rate,mineralization surface, and bone formation rate,which can be measured after the administration ofdouble tetracycline labels before the bone biopsy.The diagnosis of osteomalacia in our patients wasobvious from the clinical presentation, biochemicalfinding and radiological images. Therefore, therewas no need for an invasive pro c e d u re liketranscortical bone biopsy to establish the diagnosis.
156The Influence of Insufficient exposure to Sunlight on Vitamin D Deficiency and Related ... June 2007We treated our patients with oral vitamin D(Ergocalciferol) 600,000 U per week for two weeks;then every other week for two doses and then oncemonthly for three months. We closely observedthem for clinical features or biochemical finding ofvitamin D intoxication such as bone resorption,h y p e rcalcemia, hypercalciuria, and/or re n a lfunctional impairment. We did not encounter anycomplication when using such large doses ofvitamin D in healthy young patients. Hyperc a l c e m i adue to high dose of vitamin D has been reported infew previous studies, where hypercalcemia wasobserved in older patients with a dose of 2000IU/day and in one patient receiving a single oraldose of 600,000 IU. We did not have thiscomplication possibly because our patients wereyoung, healthy and without renal impairment andwe treated them for short period of time. Theo c c u r rence of vitamin D intoxication is ratherunpredictable, and it may occur even after years.Although practical, high doses may not be as safeas low doses.We also treated our patient with 1-3 g ofelemental calcium per day. Serum calcium wasnormal in 87.5% of patients and that was due tocompensatory secondary hyperparathyro i d i s m .Calcium deficiency has been suggested as a causeof rickets in children with apparently goodexposure to sunlight in Nigeria and Bangladesh [8,9] .Another study also showed that a very low dietarycalcium intake might cause histologicalosteomalacia [10] .Results of treatment of patient with vitamin Dmay be judged by monitoring the improvement inclinical features, biochemical tests such as increaseof serum 25(OH)D, the decrease of serum PTH,decrease of markers of bone turnover, increase inBMD and decreased incidence of fractures.P revention of vitamin D deficiency bysupplementation with a daily dose of 400-800 IU orconsumption of milk fortified with vitamin D3 (400IU/ quart or 400 IU/ liter) is very effective but maybe impractical [ 11 ] . Higher doses are seldom necessary,but 100,000 to 300,000 IU by mouth or byintramuscular injection have been used once everysix months or once yearly because of the ease ofadministration, obviating the need of checkingcompliance [5-7] . In these studies, hypercalcemia wasnot observed.Health education in the value of sunlighte x p o s u re for at least 10 minutes daily of theu n c o v e red skin e . g ., face, arms and legs andconsumption of at least 1 g of calcium daily fromdairy product, green vegetables and/ or fishconsumption should be widely recommended.CONCLUSIONOsteomalacia due to vitamin D deficiencysecondary to insufficient sunlight exposure andinadequate dairy product consumption is notuncommon in women of Jahra region of Kuwait inspite of the sunny climate. They impro v e dsymptomatically and biochemically, without illeffects, after treatment with high dose of vitamin D,and after health education that helped in greatere x p o s u re to sunlight and an increase in theconsumption of dairy products to obtainapproximately 1 g of calcium daily.REFERENCES1. Holick MF. McCollum award lecture 1994. Vitamin D: newhorizons for the 21 s t c e n t u r y. Am J Clin Nutr 1994; 60:619-630.2. Holick MF. Environmental factors that influence thecutaneous production of vitamin D. Am J Clin Nutr 1995;61:638-645.3. Sedrani SH, Elidrissy AWTH, El Arabi KM. Sunlight andvitamin D status in normal Saudi subjects. Am J Clin Nutr1983; 38:129-132.4. Norman AW, Roth J, Orci L. The vitamin D endocrinesystem: steroid metabolism, hormone receptors, andbiological response (calcium binding proteins). Endocr Rev1982; 3:331-366.5. Sedrani SH, Elidrissy AWTH, El Arabi KM. Sunlight andvitamin D status in normal Saudi subjects. Am J Clin Nutr1983; 38:129-132.6. Matsuoka LY, Wortsman J, MacLaughlin J, Hollis BW, Lu Z,Holick MF. Clothing prevents ultraviolet-B radiationdependentphotosynthesis of vitamin D. J Clin EndocrinolMetab 1992; 75:1099-1103.7. Matsuoka LY, Ide L, Wortsman J, MacLaughlin J, Holick MF.Sunscreens suppress cutaneous vitamin D synthesis. J ClinEndocrinol Metab 1987; 64:1165-1168.8. Fischer PR, Rahman A, Cimma JP, Kyaw-Myint TO, KabirAR, Talukder K. Nutritional rickets without vitamin Ddeficiency in Bangladesh. J Trop Pediatr 1999; 55:291-293.9. Okonofua F, Gill DS, Alabi ZO, Thomas M, Bell JL,Dandona P. Rickets in Nigerian children: a consequence ofcalcium malnutrition. Metabolism 1991; 40:209-213.10. Marie PJ, Pettifor JM, Ross F, Glorieux FH. Histologicalosteomalacia due to dietary calcium deficiency in children.N Engl J Med 1982; 307:584-588.11. Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 andcalcium to prevent hip fractures in elderly women. N EnglJ Med 1992; 327:1637-1642.
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