Elmer

Press

Case Report

J Endocrinol Metab 2013;3(1-2):38-40

A Case of Metabolic Encephalopathy Triggered by Food Supplements

id!i "ansala# d # $i%e& Manoc!ab# 'i%i( $anesc(c# Jenni)er *ell&c

Abstract
0 12-&ear-old Ca(casian )e+ale 3it! !istor& o) +(ltiple sclero- sis (M4)# osteoporosis and breast cancer presented 3it! 3ea5ness# constipation# con)(sion and s!ort ter+ +e+or& loss. 6er +etabolic pro)le s!o3ed pre renal a,ote+ia and se%ere !&percalce+ia (17.2 +89). 088ressi%e +edical +ana8e+ent led to )a%orable resol(tion o) !er s&+pto+s. 0 co+plete dia8nostic 3or5 (p )or t!e etiolo8& o) !&percalce+ia 3as t!en per)or+ed. :/6 le%els 3ere s(ppressed at 1.7 p8;+' aro(sin8 s(spicion )or !&percalce+ia d(e to +ali8- nanc& (prior !istor& o) breast cancer %s. ne3 pri+ar&). :/6r: (0.8 p+ol;')# /46 (0.723 <=;') and )ree /4 (2.8> n8;d') 3ere 3it!in nor+al li+its. 21- !&dro?& @ita+in $ le%el 3as !i8! at 27 n8; +'# 3!ile 1-21 di!&dro?& %ita+in $ 3as 28 p8;+'. Re%ie3 o) !er +edication list s!o3ed dail& inta5e o) 800 (nits o) %ita+in $. /!e patient denied o%erdosin8 on prescription %ita+in $ b(t later ad+itted t!at s!e 3as in8estin8 an e?pensi%e nat(rall& deri%ed 8el preparation containin8 abo(t 17#000 <= o) %ita+in $3 dail&. /!is 3as one o) se%eral alternati%e +edications prescribed to !er b& an online practitioner )or !er M4 and osteoporosis. :atient 3as co(n- seled on potential side e))ects o) e?cessi%e %ita+in $ s(pple+enta- tion and t!ese 3ere 3it!!eld at t!e ti+e o) disc!ar8e. Keywords: 6&percalce+ia; @ita+in $; Co+ple+entar& and alternati%e +edicine

Introduction
Co+ple+entar& and alternati%e +edications (C0M) reMan(script accepted )or p(blication Jan(ar& 31# 2013
a

$epart+ent o) Medicine# 4= A =pstate Medical =ni%ersit&# A# 13210. =40

cei%e i++ense attention and (tili,ation in toda&-s era. /!e $epart+ent o) Bastroenterolo8&# 4= A =pstate Medical 200> =ni%ersit&# A# 13210# =40 ational c 6ealt! $epart+ent o) Endocrinolo8&# 4= A =pstate Medical =ni%ersit&# A# <nter%ie3 13210. =40 4(r%e& d ( 6<4) Correspondin8 a(t!or: id!i "ansal# 10 :residential :la,a# 0pt 208# 4&rac(se# A# 13202# =40. E+ail: s!o3ed dr.nidiC8+ail.co+ t!at as +an& as doi: !ttp:;;d?.doi.or8;10.4021;De+1473 38 percent o) 0+erican ad(lts (se C0M. 0ppro?i+ate l& 34 billion dollars &earl& is spent on C0M in t!e =.4. alone. :op(lar a+on8st C0M are %ita+in s(pple+ents# C!inese !erbs# sa3 pal+etto and )s! oil. <ndi%id(al s recei%e n(trients )ro+ dietar& so(rces# b(t o)ten ta5e or

are prescribed s(pple+ents s(c! as )s! oil and %ita+in $ b& di))erent !ealt! care pro%iders incl(din8 p!&sicians# n(rse practitioners# c!iropractors and practitioners o) alternati%e +edicine. $(e to a +isconception on t!e part o) t!e patient abo(t t!e reE(ired dose and lac5 o) co++(nication bet3een +(ltiple pro%iders# c!ronic in8estion o) inappropriatel& !i8! doses o) s(c! +edications +a& ta5e place res(ltin8 in li)e t!reatenin8 co+plications F1G. He describe s(c! a case o) a patient 3it! ac(te encep!alopat!& d(e to se%ere !&percalce- +ia associated 3it! in8estion o) inappropriatel& !i8! doses o) %ita+in $ s(pple+ents.

Case Report
0 12-&ear-old Ca(casian )e+ale# )nancial cons(ltant )or a +edicine practice 3it! a past !istor& o) +(ltiple sclerosis (M4)# osteoporosis# 38

breast cancer stat(s post l(+pecto+&# radiationirri- table; and c!e+ot!erap& 3as ad+itted 3it!cranial co+plaints o) con)(sion# s!ort ter+ +e+or&ner%e loss# !eadac!e# 8enerali,ed 3ea5ness# and)(nctions palpitations. I%er t!e pre%io(s t3o 3ee5s# s!e<< - J<< 3as )o(nd to be pro8ressi%el& con)(sed#3ere irritable# (n- able to 3al5 and beca+e8rossl& 3!eelc!air bo(nd. 4!e denied an& 3ei8!t loss#intact. s!ortness o) breat!# c!est pain# abdo+inal pain#Motor )e%er or ni8!t s3eats. e?a+inati 6er ri8!t-sided 3ea5ness secondar& to M4 3ere on treated in t!e past 3it! oral steroids# inter)eron s!o3ed "eta 1a and 8latira- +ate acetate 3it! partial increased relie) o) s&+pto+s. 4!e stated t!at s!e !ad not tone in (sed M4 +edications )or t!e past 10 &ears and bilateral !er last )are-(p 3as in 2001 3!en s!e lo3er responded 3ell to a co(rse o) oral steroids. 4!e denied dr(8 aller8ies# s+o5in8# illicit dr(8 (se or alco!ol. In p!&sical e?a+ination# patient 3as con)(sed#

0rticles K /!e a(t!ors L Jo(rnal co+pilation K J Endocrinol Metab and El+er :ressM L 333.Do)e+.or8
/!is is an open-access article distrib(ted (nder t!e ter+s o) t!e Creati%e Co++ons 0ttrib(tion 'icense# 3!ic! per+its (nrestricted (se# distrib(tion# and reprod(ction in an& +edi(+# pro%ided t!e ori8inal 3or5 is properl& cited

"ansal et al e?tre+ities 3it! 4;1 stren8t! and !&per re)e?ia in all )o(r e?tre+ities. 4ensor& e?a+ination s!o3ed intact
te+perat(re and li8!t to(c! 3it! decreased %ibrator& sense in bilateral lo3er e?tre+ities. :lantar re)e?es 3ere (p8oin8 bilaterall&. Cardio%asc(lar and rest o) s&ste+ic e?a+ination 3as 3it!in nor+al li+its.

F4G. /!e incre+ental cons(+p-

J Endocr Metab 2013;3( 2):38-40 tio n o) 1 N8; d o) %it a+ in $3 rai ses ser (+ 21!& dro ?& %it a+in $ (21( I6) $) b& app ro?i +at el& 1 n+ ol;' (0.4 N8; '). :(b lis! ed liter at(r e s(8 8es ts t!at to?i cit& +a & occ (r

6er +etabolic pro)le s!o3ed pre-renal a,ote+ia and se%ere !&percalce+ia (17.2 +89). <nitial +ana8e+ent
con- sisted o) intra%eno(s )(id bol(s )ollo3ed b& a contin(o(s drip titrated to a 8oal (rine o(tp(t o) 100 +';!o(r. Calci(+ le%els slo3l& ca+e do3n to a le%el o) >.2 +8;d'. 6er ac(te 5idne& inD(r& also resol%ed and 3as li5el& d(e to !&percal- ce+ia and de!&dration. 0 co+plete dia8nostic 3or5 (p )or !&percalce+ia 3as t!en per)or+ed. :/6 le%els 3ere s(p- pressed at 1.7 p8;+' aro(sin8 s(spicion )or !&percalce+ia d(e to +ali8nanc& (prior !istor& o) breast cancer %s ne3 pri+ar&). 6o3e%er !er :/6r: le%el 3as not ele%ated (0.8 p+ol;'). /46 (0.723 <=;') and )ree /4 (2.8> n8;d') 3ere also in nor+al ran8e. 4er(+ al5aline p!osp!atase le%els (107 <=;') 3ere also nor+al 21 6&dro?& %ita+in $ 3as !i8! at 27 n8;+' (10 - 11 n8;+')# 3!ile 1# 21$i!&dro?& %ita+in $ 3as lo3 nor+al at 28 p8;+' (10 - 71 p8;+').

Re%ie3 o) !er +edication s!o3ed t!at s!e 3as ta5in8 b(propion 300 +8 dail&# tolterodine 4 +8 dail&#
dia,epa+ 2 +8 t!ree ti+es a da&# 8abapentin 700 +8 t!ree ti+es a da&# pantopra,ole 40 +8 dail&# 800 (nits o) %ita+in $ and 100 +8 o) calci(+ dail&.

Hit! li+ited s(n e?pos(re in Central e3 Aor5 3eat!- er# !o3 o(r patient +ana8ed to ac!ie%e s(c! a
de8ree o) s&+pto+atic !&per%ita+inosis $ 3as (nclear. 4!e denied o%erdosin8 on prescription %ita+in $ b(t later ad+itted to in8estin8 a nat(rall& deri%ed 8el preparation containin8 ap- pro?i+atel&17# 000 international (nits o) %ita+in $ dail& )or past 10 +ont!s. /!is 3as one o) se%eral +edications s!e 3as prescribed online b& a practitioner o) alternati%e +edicine to c(re !er +(ltiple sclerosis and osteoporosis.

He co(nseled and pro%ided in)or+ation to t!e patient on t!e potential side e))ects o) e?cessi%e %ita+in
$ s(pple+en- tation and ot!er alternati%e preparations. 4!e 3as instr(cted to discontin(e all !er s(pple+ents and 3as disc!ar8ed )ro+ t!e !ospital a)ter co+plete reco%er&.

Discussion
Epide+iolo8icall& %ita+in $ s(pple+entation !as s!o3n bene)ts in conditions s(c! as osteoart!ritis#
+(ltiple scle- rosis# !&pertension# ins(lin resistance# lipid abnor+alities# +ood a))ects and e%en pre%ention o) so+e cancers F2# 3G. /!e a+o(nt (p to 3!ic! a s(bstance is tolerated 3it!o(t ad- %erse e))ects in t!e +aDorit& o) pop(lation is considered as its sa)e (pper li+it. :er t!e latest reco++endations o) t!e <nstit(te o) Medicine# t!e tolerable (pper li+it in ad(lts )or %ita+in $ is 4#000 <=;da&

3it! 21(I6)$ concentrations be&ond 100 n+ol;' (200 N8;') F2G. @ita+in $ to?icit& +a& present clinicall& 3it! na(sea# %o+- itin8# abdo+inal cra+ps# constipation# poor appetite# 3ei8!t loss# con)(sion# perioral tin8lin8 sensations# 3ea5ness and !eart r!&t!+ abnor+alities. @ita+in $ is a )at sol(ble %ita- +in 3it! a lon8 !al)-li)e appro?i+atel& 2 +ont!s# 21(I6) $ 3!ic! is t!e +ain transport )or+# !as a !al)-li)e o) appro?i- +atel& 11 da&s 3!ereas t!e acti%e 1# 21 di!&dro?& %ita+in $ (1# 21(I6)

F1G. <n %ita+in $ to?icit& d(e to e?cessi%e in8estion o) c!olecalci)erol (21-!&dro?&%ita+in $3) or er8ocalci)erol
(21-!&dro?&%ita+in $2)# !i8! le%els o) ser(+ 21(I6)$ 3it! nor+al ser(+ 1# 21(I6)
2$ le%els !a%e been reported

2$) !as a !al)-li)e o) appro?i+atel& 11 !o(rs

F7# >G. /!e li%er con%erts al+ost all %ita+in $ to 21(I6) $ t!ro(8! s(bstrate-dependent c&toc!ro+e
:410-lin5ed o?idases 3!ic! are loosel& re8(lated F8G. @ita+in 21(I6)$ t!ere)ore re)ects t!e a+o(nt o) parent %ita+in $. <t is li5el& t!at in cases o) %ita+in $ to?icit&# it is t!e 21(I6) $ t!at is responsible )or t!e !&percalce+ia. 0t !i8!er concentra- tions# %ita+in $ +etabolites s(c! as 21(I6)$ +a& co+pete )or bindin8 at %ita+in $ receptor sites# t!ereb& prod(cin8 e))ects si+ilar to t!ose o) 1# 21(I6)
2$ b& initiatin8 transla-

%ita+in $ bindin8 protein ($":) bindin8 capacit& and )ree0lso 21(I6)$ enter t!e cells directl& a))ectin8 t!e 8ene+os e?pression F7# ># 10G. t /!e =.4. Oood and $r(8 0d+inistration (O$0) s(p re8(la- tions )or dietar& s(pple+ents are not t!e sa+e as ple t!ose )or prescription or o%er-t!e-co(nter dr(8s. <n 8eneral# +e t!e re8(- lations )or dietar& s(pple+ents are less strict and nts 8enerall& t!e +an()act(rer does not !a%e to pro%e t!e !a% sa)et& and e))ec- ti%eness o) a dietar& s(pple+ent be)ore it e is +ar5eted. Ince a dietar& s(pple+ent is on t!e +ar5et# not t!e O$0 +onitors sa)et& and prod(ct in)or+ation (label bee clai+s and pac5a8e inserts)# and t!e Oederal /rade n Co++ission (O/C) +oni- tors ad%ertisin8. /!e ational test Center )or Co+ple+entar& and 0lternati%e Medicine ed ( CC0M) de)nes co+ple+en- tar& and alternati%e +edicine in (C0M) as a 8ro(p o) di%erse +edical and !ealt! care pre s&ste+s# practices# and prod(cts t!at are not 8enerall& 8na considered part o) con%entional +edicine. <t incl(des nat(ralnt s(bstances s(c! as dietar& s(pple+ents# probiotics# !erbs; +ind and bod& +edicine li5e +editation# ac(p(nct(re# +assa8e# rei5i; be!a%ioral t!erap& s(c! as !&p- not!erap&# etc. Ri8oro(s# 3ell-desi8ned clinical trials )or +an& C0M t!erapies are o)ten lac5in8; t!ere)ore# t!e sa)et& and e))ecti%eness o) +an& C0M t!erapies are (ncertain. 4o+e dietar& s(pple+ents +a& interact 3it! +edications or ot!er s(pple+ents# +a& !a%e side e))ects o) t!eir o3n# or +a& contain potentiall& !ar+)(l in8redients not listed on la- bels.

tion o) %ita+in $ receptor-responsi%e 8enes F2G. 0lso# !i8!er concentrations o) 21(I6)$ +a& e?ceed

0rticles K /!e a(t!ors L Jo(rnal co+pilation K J Endocrinol Metab and El+er :ressM L 333.Do)e+.or8

3 2

Encep!alopat!& d(e to Oood 4(pple+ents 3o+en# n(rsin8 +ot!ers# or c!ildren. :atients s!o(ld noti)& all t!eir !ealt! care pro%iders abo(t an&
co+ple+entar& and alternati%e practices t!e& are (sin8 so t!at t!e& bene)t )ro+ sa)e and coordinated care F11G.

:atients s!o(ld be re+inded t!at Pnat(ralQ does not al- 3a&s +ean Psa)eQ. <t is i+portant to contin(e to
+onitor di- etar& s(pple+ents (not D(st !erbal prod(cts) t!at +a& !a%e interaction and to?icit& iss(es. <t is also eE(all& i+portant to ed(cate patients and clinicians on s(pple+ents t!at do not !a%e pro%en sa)et& iss(es d(e to lac5 o) rob(st st(dies# b(t !a%e been s!o3n in s+all laborator& st(dies and case reports to !a%e sa)et& concerns. /!ere is a need to be %i8ilant and constantl& (pdated abo(t 5no3n and possible ad%erse e))ects. Medical pro%iders s!o(ld be a3are o) a patient-s !o+e en%iron+ent and care tea+ t!at +a& incl(de )a+il& +e+bers and C0M practitioners reco++endin8 treat+ents o(tside o) c(rrent establis!ed practice. /!ese treat+ents in select cases +a& be deleterio(s to a patient-s !ealt! and earl& detection b& a traditional +edical pro%ider is li5el& t!e 5e& to pre%entin8 possible ad%erse o(tco+es.

!ttp:;;n cca+.n i!. 8o%;!e alt!;3! 2010;30(1):81-8>. 2. @iet! R. @ita+in $ s(pple+entation# 21-atisca !&dro?&%i- ta+in $ concentrations# and sa)et&. 0+ J Clin +. :(b o:$34 (tr. 1222;72(1):842-817. >. 3. R(er)eld =# Ma5 R6. @ita+in $ 0ccess de)cienc& and to?icit& in c!ronic 5idne& disease: in ed searc! o) t!e t!erape(tic 3indo3. :ediatr ep!rol. 20t! 2010;21(12):2413-2430. 0(8(st 4. <nstit(te I) Medicine (<IM) $ietar& Re)erence <nta5es )or Calci(+ and @ita+in $. 0%ailable 2012. at: 333.io+.ed(. 0ccessed 20t! 0(8(st 2012.

J Endocrinol Metab 2013;3(12):38-40

1.

Jones B. :!ar+aco5inetics o) %ita+in $ to?icit&. 0+ J Clin (tr. 2008;88(2):1824-1874. 7. Jones B. E?pandin8 role )or %ita+in $ in c!ronic 5idne& disease: i+portance o) blood 21-I6-$
le%els and e?tra- renal 1alp!a-!&dro?&lase in t!e classical and nonclassi- cal actions o) 1alp!a#21-di!&dro?&%ita+in $(3). 4e+in $ial. 200>;20(4):317-324.

>.

6olic5 MO. @ita+in $ de)cienc&.

200>;31>(3):277-281.

En8l J

Med.

Declaration
0(t!ors declare no con)icts o) interest. 0(t!ors declare t!at no )nancial assistance 3as ta5en )ro+ an&
so(rce. 0(t!ors declare t!at t!e& !a%e no co++ercial or proprietar& interest in an& dr(8# de%ice# or eE(ip+ent +entioned in t!e s(b+it- ted article.

8. B. "ile,i5ian J:# Rais, 'B# Rodan B0# eds. @ita+in $ and analo8(es. <n: Jones :rinciples o)
bone biolo8&. 3rd

ed. 4an $ie8o# C0: 0cade+ic :ress# 2008. 2. :rosser $E# Jones B. En,&+es in%ol%ed in t!e acti%a- tion and inacti%ation o) %ita+in $. /rends
"ioc!e+ 4ci. 2004;22(12):774-7>3.

10.

Mas(da 4# "&)ord @# 0rabian 0# 4a5ai A# $e+a& M"# 4t-0rna(d R# Jones B. 0ltered

p!ar+aco5inetics o) 1alp!a#21-di!&dro?&%ita+in $3 and 21!&dro?&%ita+in $3 in t!e blood and tiss(es o) t!e 21!&dro?&%ita+in $- 24-!&dro?&lase (C&p24a1) n(ll +o(se. Endocrinolo8&. 2001;147(2):821-834.

References 1.
Mo&ad M0. =nder-!&ped and o%er!&ped dr(8-di- etar& s(pple+ent interactions and
iss(es. =rol (rs.

11.

ational Center )or Co+ple+entar& and 0lternati%e Medicine ( CC0M). 0%ailable at:

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0rticles K /!e a(t!ors L Jo(rnal co+pilation K J Endocrinol Metab and El+er :ressM L 333.Do)e+.or8