Case of the Month: Pediatric ESAP

esap 2017

This case highlights the newest edition of Pediatric Endocrine Self-Assessment Program (Pediatric ESAP). Test your clinical knowledge and prepare for your exam. Available on the online store.


Clinical Vignette

You are called to consult on a 12-year-old girl who was hospitalized after presenting with abdominal pain, vomiting, and constipation.

Laboratory test results:

Calcium = 15.2 mg/dL (3.8 mmol/L) (reference range, 8.8-10.8 mg/dL [2.2-2.7 mmol/L])

Creatinine = 1.8 mg/dL (159.1 µmol/L) (reference range, 0.5-1.0 mg/dL [44-88 μmol/L])

PTH = <3 pg/mL (<3 ng/L) (reference range, 10-55 pg/mL [10-55 ng/L])

Total 25-hydroxyvitamin D = 210 ng/mL (524.2 nmol/L) (reference range, 20-50 ng/mL [5-125 nmol/L])

Renal ultrasonography shows medullary nephrocalcinosis. You diagnosis hypervitaminosis D and obtain additional history from the child’s parents. The family has recently relocated to the area from southern California. They state they are very health conscious and eat only organic food. They describe their daughter as a “big milk drinker” who consumes 6 glasses per day of unpasteurized milk purchased from the local farmers market. The family homeschools and does not own a TV; the patient spends multiple hours playing outdoors each day. She takes no medications, but she does receive a cod liver–based supplement purchased from a local naturopathic shop. You read the label on the supplement, which states that the recommended dose of 3 pills daily contains a total of 4000 IU of vitamin D3. The parents insist they have followed the instructions on the label consistently.

Which of the following is the most likely cause of this patient’s hypervitaminosis D?

  1. Excess consumption of unpasteurized milk
  2. Excessive sunlight exposure
  3. A mutation in the CYP24A1 gene encoding 24-hydroxylase
  4. The parents are not being truthful about the amount of supplement they are administering
  5. The supplement contains higher amounts of vitamin D than is indicated on the label


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