8290 Hypervitaminosis A Induced Severe Hypercalcemia In A Patient With Cirrhosis
Authors: Vennelaganti N , Vennelaganti S , Fitzgerald R L , McCowen K C 
Published: October 2024

Abstract
Disclosure: N. Vennelaganti: None. S. Vennelaganti: None. R.L. Fitzgerald: None. K.C. McCowen: None.
Introduction The liver stores vitamin A in hepatic stellate cells and regulates its absorption through bile production and distribution via retinol-binding protein 4 and transthyretin synthesis. Cirrhosis compromises these functions, resulting in vitamin A deficiency, which is inversely linked to the severity of nonalcoholic steatohepatitis. Addressing this deficiency in chronic liver diseases, particularly cirrhosis, is challenging due to the risk of vitamin A toxicity. This case describes a cirrhotic patient who developed hypervitaminosis A, leading to severe hypercalcemia. Clinical Case A 54-year-old male with alcoholic cirrhosis was diagnosed with hypovitaminosis A. He was prescribed 10,000 IU of vitamin A due to a low serum retinol level of less than 0.06 mg/L (reference range: 0.3-1.2 mg/L ). Two months later, he presented to the hospital with an erythematous patchy, scaling facial rash. His serum calcium corrected for albumin was high at 15.6 mg/dL. The rash and hypercalcemia, alongside vitamin A supplementation, raised suspicion of vitamin A toxicity. The patient, however, exhibited no hypercalcemia symptoms. He also had an acute kidney injury. His lab results revealed a PTH level of 10 pg/mL (normal range 15-65 pg/ml) and a normal myeloma screen, as well as normal vitamin D and TSH levels. An elevated PTHrP level of 5.2 pmol/l (normal range 0-2.3) was noted, which was attributed to the kidney injury(Cr 2.55 mg/l, eGFR 23 ml/min). Malignancy was excluded after a pan scan. Hypervitaminosis A is a clinical diagnosis, as serum vitamin A levels correlate poorly with toxicity. His serum retinol was normal at 0.83 mg/l, but his retinyl palmitate was high at 0.38 mg/L(reference range 0-0.10 mg/l), which supported our diagnosis. He received continuous IV 0.9% saline and subcutaneous calcitonin at 4 units/kg twice, and had a reduction in corrected calcium to 11 mg/dL over a week. The vitamin A-induced contact dermatitis improved with topical steroids. He was discharged; two months later, he remained asymptomatic with a corrected calcium of 11.1 mg/dL. He was not interested in further management as he was asymptomatic and serum calcium levels were improving. Labs were, however, notable for worsening renal function of unclear etiology. We will be trending his labs for improvement in serum calcium as the Vitamin A clears from his system. Clinical Lesson Vitamin A supplementation in cirrhotic patients is necessary in those with deficiency but carries a risk of toxicity. There are no definitive hepatology guidelines on the replacement of Vitamin A in patients with cirrhosis. This case emphasizes the importance of awareness of hypervitaminosis A-induced hypercalcemia in this population. Clinicians must carefully monitor and manage Vitamin A levels to avoid toxicity. Further research is essential for the management of this condition in cirrhotic patients.
Presentation: 6/2/2024