An interesting case of unintentional vitamin D toxicity in an infant due to erroneous supplement concentration: a case report.
Level 4 - case-series / case-control
Single patient case report
PubMed 37228984 · doi:10.1097/MS9.0000000000000528
What was done
Clinical, laboratory, and ultrasonographic evaluation of a 2.5-month-old infant presenting with failure to thrive, lethargy, dehydration, poor feeding, decreased appetite, 3 days of fever, nasal blockage, and noisy breathing. Biochemical testing included total serum calcium, 25-hydroxy vitamin D, and parathyroid hormone, alongside renal ultrasonography and analysis of the administered over-the-counter vitamin D formulation.
What was found
The infant had total serum calcium of 6.0 mmol/l, serum 25-hydroxy vitamin D >160 ng/ml, suppressed parathyroid hormone of 3.7 pg/ml, a urinary tract infection, and nephrocalcinosis on ultrasound. Analysis of the supplement revealed a manufacturer concentration error delivering 42,000 IU of vitamin D instead of the intended 800 IU per 0.5 ml.
Why it matters
It highlights that manufacturing concentration errors in pediatric over-the-counter formulations can cause massive accidental overdoses and life-threatening hypervitaminosis D in infants.
Limits
This is a single-patient case report (n=1). The abstract does not report the treatment provided, the duration of exposure, or long-term renal and developmental outcomes.
Cited by
- partial Some over-the-counter vitamin D3 and melatonin supplements have been found to contain 1,000 to 10,000 times more active ingredient than stated on the label.