Home            Past Issues            About IP            About IAP           Author Information            Subscription            Advertisement              Search  

   
Correspondence

Indian Pediatr 2014;51: 1021-1022

Vitamin D Deficiency: An Uncommon Cause of Quadriparesis

 

Chandrika Azad and *Sukhvinder Singh

Departments of Pediatrics, Government Medical College and Hospital, Chandigarh; and *Department of Medicine, HS Judge Institute of Dental Science and Hospital, Chandigarh.
Email: # chandrika_azad@yahoo.co.in

 
 
 


Vitamin D deficiency can present with neuromuscular symptoms at all ages from floppiness in infancy, delayed motor milestones in toddlers and acquired proximal muscle weakness in adolescents and young adults. Proximal limb myopathy associated with rickets is well known but truncal weakness is rare [1].

A 6-year-old girl presented with progressive weakness of body for six months and inability to get up from bed for two months. She was a vegetarian and had an aversion to milk and milk products. She received vigorous physiotherapy from a local hospital. At presentation, child had stable vitals and had pallor. Her weight was 17.5 Kg, The muscle bulk was normal, and power was MRC scale 3/5 at shoulder and hip joints and 4/5 at distal joints. Truncal and neck muscles were severely involved. Deep tendon reflexes were elicitable. There were no signs of sensory involvement, meningeal irritation, cerebral dysfunction or cranial nerve involvement. Wrist joints were widened. X-ray knee joint showed cupping and fraying of lower end of femur, upper end of tibia and fibula, and fracture of upper part of both fibulae; severe osteopenia was present. Serum calcium was 7.0 mg/ dL, phosphorus 3.1 mg/dL and alkaline phosphatase 2375 IU/L. Serum 25(OH) vitamin D levels were 5 ng/mL(normal 40-60 ng/mL) and Parathormone level was 70 pg/mL (normal 13-66 pg/mL). Serum electrolytes, renal and liver function tests, thyroid function test and anti-tissue transglutaminase antibody levels were within normal limits. Electromyography (EMG) could not be performed as patient was not cooperative; Nerve-conduction in lower limbs was done which was normal. She was given intramuscular injection of 600,000 IU of vitamin D and started on calcium supplements (200mg/kg/day). Within a week child started getting up from bed, and next week she was able to walk without support.

Vitamin D probably exerts its actions on muscles through two pathways. The genomic pathway affects calcium uptake, phosphate transport and phospholipid metabolism as well as myoblast differentiation and division involving de novo protein synthesis. Non-genomic pathway affects calcium transport and contractility apparatus [2].

Vitamin D deficiency is highly prevalent in Indian population; sun exposure, atmospheric pollution, skin pigmentation, dietary and genetic factors are important determinants for it [3]. Various disorders like malabsorption syndromes, chronic kidney and liver disorders and drugs can also lead to vitamin D deficiency [4]. Recommended daily allowance (RDA) for vitamin D in children 1-13 years of age is 600 IU/day [5]. Poor dietary habits can lead to severe vitamin D deficiency and its consequences even in the absence of pathological causes. The need of the hour is to suspect vitamin D deficiency in motor delay or muscle weakness and its prompt treatment.

References

1. Fluss J, Kern I, de Coulon G, Gonzalez E, Chehade H. Vitamin D deficiency: A forgotten treatable cause of motor delay and proximal myopathy. Brain Dev. 2014;36:84-7.

2. Bischoff-Ferrari HA. Relevance of vitamin D in muscle health. Rev Endocr Metab Disord. 2012;13:71-7.

3. Rathi N, Rathi A. Vitamin D and child health in the 21st century. Indian Pediatr. 2011;48:619-25.

4. Levine M, Zapalowski C, Kappy M. Disorders of calcium, phosphate, parathyroid hormone and vitamin D metabolism. In: Kappy MS, Allen DB, Geffner ME, editors. Principles and Practice of Pediatric Endocrinology. Springfield, IL: Charles C. Thomas Co; 2005:695-814.

5. Ross AC, Taylor CL, Yaktine AL, Del Valle HB. Dietary Reference Intakes for Calcium and Vitamin D. Committee to Review Dietary reference Intakes for Vitamin D and calcium. Food and Nutrition Board, Institute of Medicine. Washington D.C: The National Academies Press; 2011.

 

Copyright 1999-2014 Indian Pediatrics