Severe vitamin D deficiency induced myopathy associated with rhabydomyolysis

• DOI: 10.4103/1947-2714.112491
• Publication Date: 2013-05-27T09:34:42Z
• Authors: Khalid Rasheed; Pooja Sethi; Eric Bixby
• Keywords: Muscle weakness; Tetany; Erythrocyte sedimentation rate

Dear Editor,

Although epidemic, vitamin D deficiency is still under-diagnosed.[1] In 30% of patients it can present as proximal muscle weakness before the biochemical signs appear leading to unnecessary investigative work up. So in at-risk individuals should be kept one differential diagnosis for weakness, condition reversible and easily treated with calcium supplementation.

A 33-year-old black female, was referred our hospital because elevated Creatinine kinase. She has been having difficulty getting up from chair over last couple months. also complained generalized aches pains while doing her routine work. a mother four children on orlistat following diet losing weight. On physical examination, bulk tone normal; power 3/5 flexors extensors hip shoulder. There no other neurological deficit.

Laboratory parameters [Table 1] revealed hypochromic microcytic anemia due severe iron deficiency. B12, thyroid function tests, erythrocyte sedimentation rate, serum magnesium, potassium phosphate levels were normal. A search inflammation or causes myopathy negative which included an auto-antibody screen such ANA, Rheumatoid factor anti JO-1 antibodies. Serum ionized low normal alkaline phosphatase but borderline high Parathyroid hormone (PTH) levels. Her 25-hydroxy extremely (4 ng/ml, reference range > 30-100). Levels Kinase, Aldolase, myoglobin Lactate Dehydrogenase (LDH) elevated. Electromyography To rule out myositis, biopsy left deltoid done showed non-specific minimal fiber atrophy [Figure ​[Figure1a1a–c]. Keeping consideration risk factors Orlistat intake, less sun exposure, melanin pigment, poor dietary intake Deficiency associated rhabydomyolsis made based clinical findings. Medical treatment initiated, withdrawn. biochemistry values along tenderness improved follow-up 2 months.

Table 1

Laboratory parameters

Figure 1

(a) small cluster atrophic cells (small arrow) some more myocytes bottom right. They are separated by fat (×4). (b) Centered fibers ragged irregular white arrow). One myocyte ...

Vitamin defined level than 20 ng/ml between 21 ng 29 considered relative insufficiency.[2] Lack sunlight higher skin content, insufficiency led patient. affects body well interfere absorption D. McDuddie demonstrated that mean significantly reduced compared baseline after 1 month Orlistat, despite multivitamin supplementation including D.[3]

In mainly myopathy. below increased sway 10 leads difficulties rising chair, inability ascend stairs pain discomfort muscular effort patient.[4] Clement et al. highlighted importance multiple myeloma, common cause musculoskeletal increase falls yet often goes unrecognized.[5] Furthermore, Glucecek al hypercholesterolemic intolerant statins myositis-myalgia tahn general population without And D, statin could successfully reintroduced 90% recurrent myositis-myalgia, reflecting interaction skeletal muscles.[6] Basis this hypothesis contains receptors modulate various transcription cells,[7] mediating cell proliferation differentiation into mature type II fibers. responsible active transportation sarcoplasmic reticulum necessary sarcomeric contraction shown play role maintenance postural equilibrium.[8]

The assessment 25 OHD (25 hydroxy D) only reliable test may development (low Alkaline phosphatase) bone disease.[2] Elevation enzyme creatinine kinase reported minority related weakness,[9] patient pointing towards significant damage. Muscle not indicated if done, shows inflammatory reaction. The ultimate evidence rests response therapy. Proximal strength strikingly improves when increases 4 16 continues improve 40 ng/ml.[10]

We conclude finding typical constellation alterations limit additional costly invasive neuromuscular workup dysfunction. patient, early therapeutic trial warranted. lack objective improvement about adequate dosage indicates need reevaluation diagnosis.