Case 28: Bilateral Hip Pain
Layne Kerry in 100 Diagnostic Dilemmas in Clinical Medicine, 2017
A 64-year-old woman presented to the emergency department complaining of lower back and bilateral hip pain. She explained that she had noticed that she had lower back pain around 6 months ago, following exertion or short periods of immobility. The lower back pain was now present for most of the day and was becoming increasingly severe. She also described bilateral hip pain that had been present for around 3–4 months. This was initially only present when she was walking upstairs or on a gradient but was now limiting her mobility indoors. She had been unable to attend her job as a seamstress for the past 2 months due to the worsening pain. She denied any preceding injuries. She had no symptoms of fever. On direct questioning, she described night sweats and 7 kg unintentional weight loss within the past 4–6 weeks. She denied altered sensation or episodes of incontinence. Her past medical history included pulmonary tuberculosis, which was treated 2 years earlier, and vitamin D deficiency. She took intermittent courses of cholecalciferol. She looked after her grandchildren on weekdays. She travelled to Bangladesh every summer and stayed with family in Dhaka for 4 weeks. She had last travelled there 9 months earlier. She denied smoking tobacco or drinking alcohol.
Renal Medicine
Ben Lovell, Paul Bentley in Memorizing Medicine: A Revision Guide, 2007
Skin • Uraemia: pruritus (scratch marks), brown nails, hyperpigmented 'frost' or sallow, injected sclera • Underlying cause: vasculitis, scleroderma, amyloid, partial lipodystrophy, angiokeratoma • Complications: pallor (anaemia), subcutaneous or scleral calcification ( I Ca2*), tophi (gout) Cardiac • Fluid overload: pulmonary and peripheral oedema, JVP t (or i if salt-wasting) • Pericarditis; tamponade (Kussmaul's sign - paradoxical JVP T on inspiration), chest pain • Ischaemic heart disease, dilated cardiomyopathy: multifactorial, inc. hypertriglyceridaemia, hyperhomocystinaemia, low HDL, insulin resistance, vascular calcification ABP • T: fluid overload (less commonly; 4: salt-wasting with tubular disease) Respiratory • Pulmonary oedema (SOB), pleurisy (chest pain), pleural effusion, pulmonary fibrosis Respiratory pattern • Hiccups, uraemic fetor, Kussmaul's breathing (deep) due to metabolic acidosis Immunocompromise, e.g. pneumonia Neurological • Encephalopathy: early - myoclonus, asterixis (hand flap), late - dementia, dysarthria, seizures • Peripheral neuropathy, restless legs syndrome • Myopathy: due to uraemia and osteomalacia GIT • Gastric ulcers due to gastrin t • Haemorrhage, due to angiodysplasia and coagulopathy, impaired platelet function Thrombocytopenia • Purpura, GIT haemorrhage (also due to impaired platelet function and coagulopathy) Urine • Frequency or nocturia may occur with tubular disease • Haematuria: IgA nephropathy, vasculitis or reflecting coagulopathy • Loin pain, or renal mass - suggests renal cystic disease Bones • Osteomalacia (Vit D deficiency), osteoporosis Endocrine • Amenorrhoea, impotence, growth retardation (in children) Systemic • Anaemia (depression, fatigue) • Anorexia, weight loss, cachexia; hypothermia C H R O N I C R E N A L FA K correct • Particular concern during acute exacerbations • Consider treating acidosis, but NaHC03 problematic due to high Na* content Intake - salt / fluid • Fluid-overload: 1 salt and fluid intake, until normal CVP or JVP obtained • Fluid-depleted: e.g. post-ATN, post-obstruction, chronic TIN -1 salt and fluid intake, until UO > 21 / day Diuretics • High-dose furosemide ± metolazone • ACE inhibitors: renoprotective in diabetes; contraindicated in renal artery stenosis Dialysis • Haemodialysis: Method: 4 hrs / session; 3 sessions / week; 250 ml / min blood dialysed via forearm AV fistula Advantage: can vary dialysate composition; flow rate or pressure (.*. diffusion gradient) Disadvantage: low creatinine clearance: 6 ml/min; loss of amino acids, vitamins; no Vit D; EPO *: Arterial injury: haemorrhage, thrombosis, ischaemia ('steal'), ABP: postural hypotension Amyloid: /^ -microglobulin: carpal tunnel syndrome Aluminium toxicity: brain (dementia); bone marrow (anaemia); bone (osteomalacia) • Chronic ambulatory peritoneal dialysis (CAPD): Method: introduce 21 dialysate into peritoneum and replace 3-4 x /day Advantage: slightly better creatinine clearance: 7 ml/min, but still loses amino acids and vitamins *: Infection of catheter, peritonitis; blockage, leakage Intake fluid - mechanical back pain, genital oedema, hernia, haemorrhoids, hydrothorax Insulin resistance due to glucose loading from dialysate, obesity Nutrition • Low protein (0.5 g/kg/day - i es uraemic toxins and acidosis); high carbohydrate; low fat • Haematinics (Fe, folate, Vit B12) and Vit C (as lost on dialysis) NSAIDs - avoid; also avoid aminoglycosides EPO (human recombinant erythropoeitin, slow-IV or subcut) &: ABP T; thrombocytosis; flu-like syndrome - may also require occasional blood transfusion with diuretic cover Y : hYperlipidaemia - simvastatin hYperglycaemia - avoid metformin, chlorpropamide; caution with insulins (due to risk of 'hypos') hYperP04aemia - Rx first to avoid ectopic calcification: P04 restriction; oral P04 binders: MgC03 or CaC03 hYpoCalcaemia - la-hydroxylated cholecalciferol; calcitriol; CaC03, high-dose: 1 es PTH and i es P04 Symptomatic • Hiccups or pruritus: chlorpromazine • Peptic ulcers: omeprazole Surgical - renal transplant % : • Rejection (immunologic, ureteric anastomosis failure); immunosuppression (infections, neoplasia) • Vascular: polycythaemia, atherosclerosis, hypertension Secondary renal failure: treat underlying cause - diabetes, hypertension, SLE, etc.
Reference concentrations of cholecalciferol in animals: a basis for establishing non-target exposure
Published in New Zealand Journal of Zoology, 2013
AAC Fairweather, CT Eason, PA Elder, CMF Eason, D Arthur
Cholecalciferol (vitamin D3) is widely used as a vertebrate pesticide in New Zealand. However, cholecalciferol also occurs naturally in animals. Therefore, when trying to determine whether a non-target animal has been exposed to cholecalciferol baits, knowledge of the baseline cholecalciferol concentrations in the animal's plasma and tissue is required. We analysed cattle, sheep, pig, deer, dog and cat plasma and liver samples for the vitamin D3 metabolite 25-hydroxycholecalciferol (25-OHD), a sensitive biomarker for cholecalciferol. Based on these data and a literature search we present 25-OHD reference ranges. We also examined the literature for 25-OHD concentrations in poisoned animals and compared these to the reference ranges. Where plasma and liver samples have 25-OHD concentrations at least four times higher than our reference ranges it is likely that the animal has been exposed to cholecalciferol baits. 25-OHD concentrations 10 times higher than the reference range indicate ingestion of abnormally high amounts of cholecalciferol.
Pilot Study: Potential Role of Vitamin D (Cholecalciferol) in Patients With PSA Relapse After Definitive Therapy
Published in Nutrition and Cancer, 2005
Tony Choon Seng Woo, Richard Choo, Mary Jamieson, Sarat Chander, Reinhold Vieth
Abstract: When local treatments for prostate cancer have failed, and prostate-specific antigen (PSA) rises in the absence of symptoms, there is little consensus as to the best management strategy. Calcitriol has been shown to prolong the doubling time of PSA in this context, but near-toxic doses are required. We investigated the effect of the nutrient vitamin D (cholecalciferol), a biochemical precursor of calcitriol, on PSA levels and the rate of rise of PSA in these patients. Fifteen patients were given 2,000 IU (50 μg) of cholecalciferol daily and monitored prospectively every 2-3 mo. In 9 patients, PSA levels decreased or remained unchanged after the commencement of cholecalciferol. This was sustained for as long as 21 mo. Also, there was a statistically significant decrease in the rate of PSA rise after administration of cholecalciferol (P = 0.005) compared with that before cholecalciferol. The median PSA doubling time increased from 14.3 mo prior to commencing cholecalciferol to 25 mo after commencing cholecalciferol. Fourteen of 15 patients had a prolongation of PSA doubling time after commencing cholecalciferol. There were no side effects reported by any patient. Further study is needed to confirm this finding and to explore the potential therapeutic benefit of nutrient vitamin D in prostate cancer.
Pharmacokinetics of two formulations of alendronate sodium/cholecalciferol (vitamin D
Published in Clinical Research and Regulatory Affairs, 2013
Sudhakar Koundinya Tippabhotla, Satyanarayana Thota, Sohel Md. Khan, Chaitanya Gadiko, Sandeep Yergude, Raju Cheerla, Mukesh Nakkawar, Madhava Rao Betha, Ramakrishna Battula, Venkateswarlu Vobalaboina
A fixed dose combination of alendronate and cholecalciferol (vitamin D3) 70 mg/5600 IU tablets has been indicated for the treatment of osteoporosis. This study was aimed to assess bioequivalence between test and reference formulations of alendronate sodium/cholecalciferol (vitamin D3) tablets 70 mg/5600 IU in 110 healthy adult male volunteers under fasting conditions. This was an open label, randomized, single dose, two way cross-over study, separated by a washout period of 14 days. All possible efforts were made to stabilize the baseline endogenous levels of cholecalciferol. Blood samples were collected from 96 h pre-dose to 96 h post-dose and 0–24 h for cholecalciferol and alendronate, respectively. Quantification of alendronate and cholecalciferol was done using distinct validated LC-MS/MS methods. Two baseline adjusted methods, method-I (subtraction of the average concentration from each post-dose concentration) and method-II (subtraction of the individual AUC from post-dose AUC) were applied for deriving the AUC0–t parameter of cholecalciferol, among which bioequivalence was concluded based on data obtained using method-I. The 90% CI of Cmax and AUC0–t for alendronate and baseline adjusted cholecalciferol were within the regulatory acceptance limit of 80.00–125.00% and considered as bioequivalent.
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