eMedicine Specialties > Endocrinology > Metabolic Disorders

Vitamin A Toxicity: Follow-up

Author: Mohsen S Eledrisi, MD, FACP, FACE, Consultant, Department of Internal Medicine, Division of Endocrinology and Metabolism, King Abdulaziz National Guard Medical Center, Saudi Arabia
Coauthor(s): Kevin McKinney, MD, Assistant Professor, Department of Medicine, Division of Endocrinology and Metabolism, University of Texas Medical Branch at Galveston; Mohammad S Shanti, MD, ABEM, Chair, Department of Emergency Medicine, King Faisal Specialist Hospital and Research Center
Contributor Information and Disclosures

Updated: Sep 2, 2009

Follow-up

Further Inpatient Care

  • Admit patients with the following symptoms to the hospital:
    • Altered mental status
    • Severe dehydration
    • Neurologic deficits
    • Metabolic derangements
    • Liver toxicity
    • Significant hypercalcemia
  • Patients with increased intracranial pressure may need therapeutic lumbar punctures or further treatment with medications such as diuretics and mannitol.
  • Patients with symptomatic hypercalcemia require the following:
    • Close monitoring
    • Treatment with intravenous fluids and diuretics
    • Additional therapy, including pamidronate, calcitonin, corticosteroids, or mithramycin
    • Discontinuation of vitamin A

Further Outpatient Care

  • Follow-up is recommended with a primary care physician.
  • The pigmentation of carotenemia usually disappears with the omission of carrots from the diet.
  • Patients on isotretinoin should be evaluated by their dermatologist for consideration of stopping the drug.

Deterrence/Prevention

Education on the proper required daily allowance dose of vitamin A should be provided to modify the individual's current use of vitamin supplements.

Prognosis

  • Prognosis is generally good.
  • Mortality is rare.

Patient Education

Patient education is an important part of management because many cases are due to long-term toxicity from dietary or drug supplements.

Miscellaneous

Medicolegal Pitfalls

  • Do not forget to evaluate for ingestion of other potentially toxic substances such as other vitamins, aspirin, and acetaminophen.
  • Inquire about the intake of other supplements and evaluate for possible overdose accordingly.

Special Concerns

  • High doses of vitamin A can be teratogenic, causing birth defects.
  • Isotretinoin (Accutane), a drug used for the treatment of severe forms of acne, is closely related to the chemical structure of vitamin A. The pharmacology and toxicology of these 2 compounds are similar. Birth defects if taken during pregnancy, intracranial hypertension, depression, and suicidal ideation have been reported with isotretinoin. A careful drug history to uncover this possibility is important in patients presenting with manifestations suggestive of vitamin A intoxication.
 


More on Vitamin A Toxicity

Overview: Vitamin A Toxicity
Differential Diagnoses & Workup: Vitamin A Toxicity
Treatment & Medication: Vitamin A Toxicity
Follow-up: Vitamin A Toxicity
References
Further Reading
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References

  1. Maqbool A, Stallings VA. Update on fat-soluble vitamins in cystic fibrosis. Curr Opin Pulm Med. Nov 2008;14(6):574-81. [Medline].

  2. Mawson AR. On the association between low resting heart rate and chronic aggression: retinoid toxicity hypothesis. Prog Neuropsychopharmacol Biol Psychiatry. Mar 17 2009;33(2):205-13. [Medline].

  3. Tan KP, Kosuge K, Yang M, et al. NRF2 as a determinant of cellular resistance in retinoic acid cytotoxicity. Free Radic Biol Med. Dec 15 2008;45(12):1663-73. [Medline].

  4. Genaro Pde S, Martini LA. Vitamin A supplementation and risk of skeletal fracture. Nutr Rev. Feb 2004;62(2):65-7. [Medline].

  5. Miksad R, Ledinghen V, McDougall C, et al. Hepatic hydrothorax associated with vitamin A toxicity. J Clin Gastroenterol. 2002;34:275-279. [Medline].

  6. Bhalla K, Ennis DM, Ennis ED. Hypercalcemia caused by iatrogenic hypervitaminosis A. J Am Diet Assoc. 2005;105:119-121. [Medline].

  7. Johnson-Davis KL, Moore SJ, Owen WE, et al. A rapid HPLC method used to establish pediatric reference intervals for vitamins A and E. Clin Chim Acta. Jul 2009;405(1-2):35-8. [Medline].

  8. Barker ME, Blumsohn A. Is vitamin A consumption a risk factor for osteoporotic fracture?. Proc Nutr Soc. 2003;62:845-850. [Medline].

  9. Bates CJ. Vitamin A. Lancet. Jan 7 1995;345(8941):31-5. [Medline].

  10. Hathcock JN. Vitamins and minerals: efficacy and safety. Am J Clin Nutr. Aug 1997;66(2):427-37. [Medline].

  11. Hathcock JN, Hattan DG, Jenkins MY, et al. Evaluation of vitamin A toxicity. Am J Clin Nutr. Aug 1990;52(2):183-202. [Medline].

  12. Michaelsson K, Lithell H, Vessby B, et al. Serum retinol levels and the risk of fracture. N Engl J Med. 2003;348:287-294. [Medline].

  13. Nagai K, Hosaka H, Kubo S, et al. Vitamin A toxicity secondary to excessive intake of yellow-green vegetables, liver and laver. J Hepatol. Jul 1999;31(1):142-8. [Medline].

  14. O'Donnell J. Polar hysteria: an expression of hypervitaminosis A. Am J Ther. 2004;11:507-516. [Medline].

  15. Olson JA. Adverse effects of large doses of vitamin A and retinoids. Semin Oncol. Sep 1983;10(3):290-3. [Medline].

  16. Penniston KL, Tanumihardjo S. The acute and chronic toxic effects of vitamin A. Am J Clin Nutr. 2006;83:191-201.

  17. Perrotta S, Nobili B, Rossi F, et al. Infant hypervitaminosis A causes severe anemia and thrombocytopenia: evidence of a retinol-dependent bone marrow cell growth inhibition. Blood. 2002;99:2017-2022. [Medline].

  18. Sharieff GQ, Hanten K. Pseudotumor cerebri and hypercalcemia resulting from vitamin A toxicity. Ann Emerg Med. Apr 1996;27(4):518-21. [Medline].

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Further Reading

Related eMedicine topics:
Avitaminosis A
Carotenemia [Dermatology]
Carotenemia [Pediatrics: General Medicine]
Toxicity, Vitamin
Vitamin A Deficiency
Vitamin E Toxicity

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Keywords

vitamin A toxicity, vitamin A, retinol, carotene, vitamin carotene, retinoid, carotenemia, isotretinoin, Accutane, carotenes, vitamin A alcohol, retinol ester, vitamin A overdose, vitamin A poisoning, dietary vitamin A, vitamin A supplements, provitamin A carotenoids

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Contributor Information and Disclosures

Author

Mohsen S Eledrisi, MD, FACP, FACE, Consultant, Department of Internal Medicine, Division of Endocrinology and Metabolism, King Abdulaziz National Guard Medical Center, Saudi Arabia
Mohsen S Eledrisi, MD, FACP, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, and Endocrine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Kevin McKinney, MD, Assistant Professor, Department of Medicine, Division of Endocrinology and Metabolism, University of Texas Medical Branch at Galveston
Kevin McKinney, MD is a member of the following medical societies: Texas Medical Association
Disclosure: Nothing to disclose.

Mohammad S Shanti, MD, ABEM, Chair, Department of Emergency Medicine, King Faisal Specialist Hospital and Research Center
Mohammad S Shanti, MD, ABEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Harris C Taylor, MD, Clinical Professor of Medicine, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine
Harris C Taylor, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Thyroid Association, and Endocrine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Romesh Khardori, MD, Chief, Division of Endocrinology, Metabolism and Molecular Medicine, Professor, Department of Internal Medicine, Southern Illinois University School of Medicine
Romesh Khardori, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society of Andrology, Endocrine Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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