A 52-year-old woman presented to the clinic for ongoing fatigue and weight loss during the last 6 weeks

A 52-year-old woman presented to the clinic for ongoing fatigue and weight loss during the last 6 weeks. She thinks she’s loss at least “10 pounds”. For the past week and a half, she’s noted some progressing ‘muscle cramping’ tetany, as well as ‘tingling’ sensation around her mouth and lower extremities. She’s also noted some intermittent colicky abdominal pain. On your exam, you noted a positive Chvostek’s sign. PMH: 20-year history of Crohn’s disease. She also tells you that she is a practicing vegan.

Primary Diagnosis

Vitamin D Deficiency: Vitamin D deficiency is a result of the body’s inability to absorb and maintain sufficient Vitamin D levels (Krela-Kaźmierczak et al., 2015). It can be caused by lifestyle choices (diet), environment (lack of sunlight), or underlying disease processes (Crohn’s) (Krela-Kaźmierczak et al., 2015). A vegan diet of eating plant sources puts a person at risk for Vitamin D deficiency because plants do not contain the vitamin (Krela-Kaźmierczak et al., 2015). Without UVB radiation from sunlight, the 7-dehydrocholesterol found on the skin cannot convert to the previtamin D3 (Krela-Kaźmierczak et al., 2015). Intestinal mucosa inflammation and lesions interfere and inhibit digestion and absorption of lipids, therefore, Vitamin D (Krela-Kaźmierczak et al., 2015). Signs and symptoms of Vitamin D deficiency include a positive Chvostek’s sign (twitching of the facial nerve when stimulated), bone pain, abdominal pain, fatigue, and a tingling nerve sensation (Krela-Kaźmierczak et al., 2015). The patient has a positive Chvostek’s sign. This occurs in hypocalcemia, which can be caused by Vitamin D deficiency. Her history of Crohn’s disease and vegan diet also highlight the possibility that her body has been in a constant malnourished state, which is causing her weight loss. Her hypocalcemic state, considering her age, also puts her at risk for osteoporosis (Krela-Kaźmierczak et al., 2015).

Differential Diagnoses

1. Hypoparathyroidism: Hypoparathyroidism is a result of low parathyroid hormone (PTH) that causes a low calcium level in the blood (Abate & Clarke, 2017). PTH plays an important role in calcium balance by mobilizing calcium from the skeleton and with calcium absorption through synthesis of calcitriol (1,25-dihydroxyvitamin D) (Abate & Clarke, 2017). This absorption and synthesis cannot occur if there is not a sufficient Vitamin D level. Common causes of hypoparathyroid levels include thyroid surgery, hypomagnesemia, and genetics (Abate & Clarke, 2017). Symptoms include muscle aches and spasms, tingling, fatigue, dry skin, and brittle nails (Abate & Clarke, 2017).

2. Hypomagnesemia: Hypomagnesemia is defined as a low level of magnesium in the blood (Pham et al., 2014). Magnesium has an enzymatic function that affects membrane cell function, which affects glucose metabolism as well as other electrolyte balances, including calcium (Pham et al., 2014). Having a low magnesium level can be directly correlated with a low calcium level. Inadequate absorption or letting too much go are common causes (Pham et al., 2014). Clinical manifestations include neuromuscular hyperexcitability that can range from tremors to neuropsychiatric disturbances to coma (Pham et al., 2014). In reference to the heart, it can cause arrhythmias, torsades de pointe, enhances digoxin sensitivity, and sudden death (Pham et al., 2014). The patient’s diet and disease process place her at a high risk for hypomagnesemia.

3. Malnutrition: The body can be found in a malnourished state when there are not sufficient dietary vitamins and nutrients consumed or absorbed to support a healthy state of being or due to an underlying disease process (Shashidhar, 2017). Micronutrient deficiencies can cause fatigue from having low iron, goiter development from low iodine, hypocalcemia from low Vitamin D, and night blindness from low Vitamin A (Shashidhar, 2017). Clinical signs include weight gain, fatigue, irritability, decreased subcutaneous tissue, edema, abdominal distention, and mental impairment (Shashidhar, 2017). The patient’s disease process along with her diet choice and recent weight loss places her at risk for malnutrition.

Potential Treatment Plan

Vitamin D supplementation is recommended in people who have confirmed Vitamin D deficiency (Gani & How, 2015). Oral Vitamin D supplements are available in Vitamin D3 (cholecalciferol) or Vitamin D2 (ergocalciferol) forms (Gani & How, 2015). All patients should maintain a daily calcium intake of 1300mg, since the combination of Vitamin D and calcium prevent fractures (Gani & How, 2015). Once a regimen is initiated, a three-month follow-up is required to check serum 25(OH)D concentration (Gani & How, 2015).

References

Abate, E. G., & Clarke, B. L. (2017). Review of hypoparathyroidism. Frontiers in Endocrinology, 7, 172. doi:10.3389/fendo.2016.00172

Gani, L. U., & How, C. H. (2015). PILL Series. Vitamin D deficiency. Singapore Medical Journal, 56(8), 433–437. doi:10.11622/smedj.2015119

Krela-Kaźmierczak, I., Szymczak, A., Łykowska-Szuber, L., Eder, P., Stawczyk-Eder, K., Klimczak, K., … Horst-Sikorska, W. (2015). The importance of vitamin D in the pathology of bone metabolism in inflammatory bowel diseases. Archives of Medical Science : AMS, 11(5), 1028–1032. doi:10.5114/aoms.2015.54858

Pham, P. C., Pham, P. A., Pham, S. V., Pham, P. T., Pham, P. M., & Pham, P. T. (2014). Hypomagnesemia: a clinical perspective. International Journal of Nephrology and Renovascular Disease, 7, 219–230. doi:10.2147/IJNRD.S42054

Shashidhar, H. (2017, July 19). Malnutrition. Medscape. Retrieved from https://emedicine.medscape.com/article/985140-overview