Vitamin A toxicity presenting as bone pain Revanth Baineni, Reena Gulati, CG Kumar Delhi Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research ( JIPMER), Pondicherry, India Correspondence to Dr Reena Gulati, Department of Pediatrics, JIPMER, Pondicherry 605006, India; g97rina@gmail.com Received 3 February 2016 Revised 8 May 2016 Accepted 14 May 2016 To cite: Baineni R, Gulati R, Delhi CGK. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/ archdischild-2016-310631 ABSTRACT A 4-year-old boy presented with severe bone pains, refusal to walk, diffuse bony swelling of forelimbs, skin changes and abdominal pain, with symptoms evolving over 6 weeks. Blood screening tests were normal except for raised aspartate aminotransferase (AST). Radiographs revealed thickened periosteum, widening of the diaphyses of long bones and lifted periosteum in mid- shaft of ulnae and right femur. Skeletal scintigraphy showed a high uptake of radionuclide at clinically affected and unaffected sites, suggestive of multifocal osteoblastic skeletal lesions. After repeated enquiries, his parents admitted to giving him massive doses of preformed vitamin A for over 3 months as ‘health tablets’. Surprisingly, he did not have overt liver disease typically found with much smaller doses, although the dermal changes and musculoskeletal pathology were florid. He made a full clinical recovery within 2 months of cessation of vitamin A. CASE REPORT A previously healthy 4-year-old boy presented with a history of illness for about 1½ months. An inter- mittent fever, cough and cold had subsided but poor appetite and occasional vomiting persisted, followed by severe recurrent abdominal pain and cracking of his lips. The child also presented with excruciating pain in both legs and winced on touch. There was no history of trauma. He refused to stand or walk and was empirically treated as having suspected viral myositis at the local district hospital with a partial improvement in symptoms. Another 2 weeks later, the skin over his hands and feet started peeling off and papular rash appeared over his back. At this stage his parent took him to our hospital 6 weeks after the onset of illness. At admission, the child was irritable but afebrile with normal pulse, respiration and blood pressure. He had mild pallor but no jaundice. History of any drug administration was denied by the parents. Scalp hair was sparse, coarse and brittle that was reported to be soft and abundant prior to this illness. There was peeling and deep painful cracking of both lips. Skin was shiny over the shins and face as if smeared with oil. There was peeling of skin over palms and soles that appeared flushed. Papular non-itchy erythematous rash was seen over the lower back. Tibiae were thickened and painful with extreme tenderness to touch. On examination of abdomen, soft, 4 cm non-tender liver was palpable. Spleen was not palpable. Examination of respira- tory, cardiovascular and central nervous systems did not reveal any abnormal findings. Initial laboratory work up revealed mild normo- cytic, normochromic anaemia (haemoglobin 98 G/L) with normal blood cell counts including plate- lets. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were 32 mm in the 1st hour and 4.8 mg/dL, respectively. Serum calcium was 2.5 mmol/L with normal serum phosphorus. Serum urea and creatine concentrations were within normal limits. Liver function tests were normal except for slightly elevated aspartate amino- transferase (AST) (102 IU/L). Serum alkaline phos- phatase was very high (1593 IU/L). Serum creatine kinase was normal. Echocardiogram did not show any coronary aneurysms. X-ray examination of the lower limbs at admission revealed normal bones and soft tissue. Ultrasonogram of the abdomen and Doppler examination of renal and lower limb vessels were normal. Bone marrow examination showed normal haematopoiesis. Venereal Disease Research Laboratory (VDRL) was negative. On day 3 of admission, a diffuse tender bony swelling similar to that in the middle of the lower legs appeared in the right mid-thigh and forearm. Repeat radiographs revealed thickening of the peri- osteum along the widened diaphyses of all long bones with lifting of the periosteum in the mid- shaft of ulnar bones ( figure 1) and right femur. Skeletal scintigraphy ( figure 2) revealed abnormally high uptake of technetium radionuclide in lateral parts of the supraorbital region, multiple bilateral ribs and metatarsals (clinically unaffected sites) besides the clinically affected mid-shafts of multiple long bones, suggestive of multifocal osteoblastic Figure 1 Radiograph of the left upper limb showing widened long bone diaphyses and lifted periosteum over the ulnar shaft. Baineni R, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2016-310631 1 Case report ADC Online First, published on June 6, 2016 as 10.1136/archdischild-2016-310631 Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.