An infant with hypercalcemia and rachitic changes: Question

Abstract

The patient was breast fed up to 3 months of age. She was later switched to unpasteurized goat’s milk. The mother was supplementing milk with ten drops of vitamin A with each bottle. Total daily milk intake was between 40 and 50 oz. The mother also added an unknown amount of each: vitamin E (d-alpha tocopherol) drops, blackstrap molasses, flax oil, cod liver oil, and drops of multivitamin preparation. On physical exam, the patient was afebrile; systolic blood pressure ranged between 110 and 120 s mmHg and diastolic was 80–90s mmHg (95th percentile for age, sex, and height was 103/57 mmHg). She was irritable, with a yellowish discoloration of the skin, generalized edema, and enlarged head (48.5 cm; greater than 95th percentile for age). She also had hepatomegaly with liver palpable 2 cm below the costal margin. Laboratory tests in the ED revealed serum creatinine of 61.8 μmol/l (normal for her age 18–35 μmol/l), total calcium of 3.8 mmol/l (normal range 1.20–1.38 mmol/l) and ionized calcium of 2.26 mmol/l (normal range 1.12–1.32 mmol/l). Her albumin was 20 g/l, phosphorus was 1.6 mmol/l, PTHwas low at <0.265 picomol/l (1.30–6.80 picomol/l) and alkaline phosphatase was 513 U/l (normal range for her age 150–420 U/l). Her liver enzymes were AST of 131 U/l, ALT 37 U/l, total