despite plenty of sunshine available in the tropical regions , vitamin d deficiency ( vdd ) is 
 widely prevalent among asian indians ( 1 , 2 ) . increasing awareness about the wide prevalence of 
 hypovitaminosis among asian indians has lead to widespread use of vitamin d therapy in 
 subjects with clinical features suggestive of hypocalcaemia including bone pain , muscle 
 cramps , etc . in india . such supplementation of vitamin d is perceived to be safe by general 
 physicians for asian indians who have high background prevalence of vdd . however , in western 
 countries , there have been reports of vitamin d toxicity ( vdt ) following its inadvertent use 
 ( 3 , 4 ) , and 
 serious side effects are especially common in the pediatric age group ( 5 ) . there has been no report of vitamin d therapy leading to symptoms of 
 vitamin d intoxication in india . we report the details of a patient , an asian indian infant , 
 with vdt leading to nephrocalcinosis following intramuscular vitamin d therapy . an 8-month - old male child of asian - indian origin was brought to the emergency unit with 
 complaints of persistent vomiting and refusal to feed for two weeks . a detailed history of 
 the patient revealed that child had visited a local physician due to abnormal twitching of 
 the extremities a month ago and was found to have serum calcium of 7.8 mg / dl . the patient 
 was advised a single dose , intramuscular injection of vitamin d containing 600,000 units of 
 cholecalciferol and 500 mg calcium carbonate daily . however , the child s parents did not consult the treating physician again and continued the 
 same treatment for two more weeks ( one injection of vitamin d every week ; in total three 
 injections were given over 3 wk ) . one week after the third injection of vitamin d , the child 
 developed vomiting and visited the local physician . on investigation he was found to have 
 serum calcium of 11.5 mg / dl . a provisional diagnosis of vitamin d toxicity was considered 
 and the patient was referred to the endocrine services for further management . the child was 
 born ( birth weight 2400 g ) after full term pregnancy by cesarean section ( for breech 
 presentation ) to non - consanguineous vegetarian parents . he was exclusively breast fed till 
 the age of four months , after that breast feed was supplemented with cow s milk ( by bottle ) 
 and at the age of 6 mon , semi - solid home foods ( mainly cereals ) were introduced . physical examination revealed a child of sickly appearance , who was dehydrated and 
 afebrile . further investigations revealed normal leukocyte count , urine microscopic 
 examination , renal functions ( serum creatinine 0.4 mg / dl ) , electrolytes ( serum sodium 139 
 meq / l , serum potassium 4.7 meq / l ) and liver function test ( sgpt 34 iu / l , serum alkaline 
 phosphatase 219 serum calcium was 
 found to be elevated ( 11.5 mg / dl , with normal range of 8.010.5 mg / dl ) with normal serum 
 phosphorus of 5.0 mg / dl ( 3.55.5 mg / dl ) for the age . his 
 vomiting and dehydration improved after 24 h. however his serum calcium continued to show a 
 rising trend of 12.5 mg / dl next day and 14.5 mg / dl after two days . calcitonin injection 
 ( salmon calcitonin , zydus cadila pharma , dose 4 iu / kg subcutaneously ) resulted in a prompt 
 decrease in serum calcium within 24 h. the patient s dehydration improved and he became 
 cheerful . hand x - rays showed a dense line at the margin of the metaphysis of the lower ends 
 of both the radius and the ulna ( fig . 2 hand x - rays showing dense lines at the end of radius and ulna ( white 
 arrowheads ) . ) . twenty - four - hour urinary calcium excretion ( collected before starting injection of 
 calcitonin ) was 57 mg with a body weight of 7.00 kg ( normal , less than 4 mg / kg / day ) with a 
 calcium : creatinine ratio of 0.83 ( normal ratio of 0.2 to 0.7 during infancy ) . reports of vitamin d ( radio - immunoassay ; 
 diasorin , usa ) and serum intact pth ( immuno - radiometric assay ; diasorin , usa ) showed 25 
 hydroxy vitamin d of > 100 ng / ml ( normal range of 937 ng / ml ) and undetectable pth ( normal 
 range of 753 pg / ml ) . a final diagnosis of vdt was made and the patient was scheduled for a 
 month of calcitonin injection every other day . a follow up visit 42 mon later revealed normal serum calcium , urinary 
 calcium / creatinine ratio . 3fig . 3 ultrasonography of left kidney ( size 7.2 by 3.9 cm ) 42 mon after initial episodes 
 showing persistence of medullary nephrocalcinosis with acoustic shadow ( black 
 arrow ) . ) . hand x - rays showing dense lines at the end of radius and ulna ( white 
 arrowheads ) . ultrasonography of left kidney ( size 7.2 by 3.9 cm ) 42 mon after initial episodes 
 showing persistence of medullary nephrocalcinosis with acoustic shadow ( black 
 arrow ) . there have been several reports of vdt in children , mostly from vitamin d sufficient 
 regions ( 3,4,5 ) . the present report for the first time 
 highlights the possibility and clinical features of vdt in an asian indian infant who was 
 prescribed a large dose of vitamin d ( total 1800,000 units ) . vdd was considered to be rare among indians because of plenty of sunshine ( 6 ) . however , recent studies have shown that serum 25(oh ) 
 levels are subnormal in asian indians ( 1 , 2 ) . such vdd has been reported in all age groups ; i.e. 
 neonate to adults . the paradox of wide prevalence of vdd in a sun - drenched country like 
 india is related to skin pigmentation , atmospheric pollution , and limited exposure of body 
 surface area to sunshine ( 1 , 2 ) . . guidelines 
 issued by the american academy of pediatrics ( aap ) and the national academy of sciences 
 suggest that all breastfeeding infants and non breastfeeding infants who drink < 500 ml of 
 milk per day should receive 200 iu of vitamin d per day ( 7 ) . the amount of vitamin d necessary to cause hypervitaminosis varies widely 
 among individuals . continued ingestion of 50,000 units or more daily by a person with normal 
 parathyroid function and sensitivity to vitamin d may result in poisoning ( 8) . vdt occurs over days of ingesting thousands of 
 international units of vitamin d ; therefore , it is unlikely that patients will show overt 
 manifestations of vdt with continued ingestion of vitamin d at doses available in 
 multivitamin pills ( 5 ) . early symptoms of vdt include anorexia , nausea , vomiting , weakness , lethargy , constipation , 
 and non - specific aches and pains . the long term effects of vdt are severe and at times , like 
 nephrocalcinosis , irreversible . treatment of vdt includes immediate removal of the exogenous source , 
 intravenous fluid hydration , loop diuretics ( thiazides promote calcium retention ) , 
 glucocorticoids , and a low - calcium diet . in severe cases , calcitonin , oral alendronate , and 
 pamidronate vitamin d toxicity has been seen as 
 one of the important but uncommon causes of iatrogenic nephrocalcinosis . in a retrospective 
 survey of 152 children and adolescents with nephrocalcinosis , prophylactic bolus 
 administration of vitamin d was adjudged to be a cause of nephrocalcinosis in 9% cases 
 ( 11 ) . there 
 are some reports of reversibility especially in cases with furosemide - induced 
 nephrocalcinosis and nephrocalcinosis occurring after treatment in x - linked hypophosphatemic 
 rickets ( 12 , 13 ) . resolution of vitamin d induced nephrocalcinosis has not been reported in the 
 literature . in one study , none of the five children with vitamin d induced nephrocalcinosis 
 showed resolution over the years ( 14 ) . similarly , 
 resolution was not seen even after follow - up of one to thirteen years ( 15 ) . nephrocalcinosis in a pre - term infant was found to have affected 
 renal function on long - term follow - up ( 16 ) . in a 
 study by mantan et al . , nephrocalcinosis was associated with a decline in the glomerular 
 filtration rate ( gfr ) from 82.0 ( 42114 ) ml / min per 1.73 m body surface area to 
 70.8 ( 21.3126.5 ) ml / min per 1.73 m body surface area ( p=0.001 ) , after median 
 follow - up of 35 mon . no resolution of nephrocalcinosis was seen in our case , even at 42 mon 
 after the initial episode ; however renal function remained within the normal range for the 
 infant s age . growing awareness of vdd among physicians has increased the use of vitamin d preparations . physicians dealing with 
 children need to be especially cautious when choosing from various preparations of 
 commercially available vitamin d. the treatment schedule and possible toxic effects should 
 be clearly explained to the parents , especially when an injectable preparation of vitamin d 
 is being prescribed . at the same time , parents should be clearly advised against 
 unsupervised or un - prescribed supplements of vitamin d in attempt to make bones 
 stronger .
we report vitamin d toxicity in an infant following consecutive administration use of a 
 large dose of vitamin d , causing symptomatic hypercalcemia , which was successfully managed 
 with injectable calcitonin . 
 however , the child developed bilateral medullary 
 nephrocalcinosis which persisted 42 mon after the initial episode .