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Toxicity, Vitamin: Differential Diagnoses & Workup

Author: Mark Rosenbloom, MD, MBA, FACEP, Adjunct Associate Professor of Medicine, Northwestern University Feinberg School of Medicine; Chief Executive Officer and Editorial Director, PEPID, LLC; Founder and Chairman, The Unicorn Children's Foundation
Contributor Information and Disclosures

Updated: Apr 20, 2009

Differential Diagnoses

Abortion, Threatened
Pediatrics, Gastroenteritis
Dermatitis, Exfoliative
Pediatrics, Gastrointestinal Bleeding
Headache, Migraine
Postconcussive Syndrome
Hypercalcemia
Toxicity, Ciguatera
Hyperparathyroidism
Toxicity, Fluoride
Munchausen Syndrome
Toxicity, Iron
Munchausen Syndrome by Proxy
Osgood-Schlatter Disease

Workup

Laboratory Studies

  • Acetaminophen and aspirin levels (on every suspected ingestion)
  • Electrolytes (in patients with severe vomiting or diarrhea)
  • Vitamin A
    • Retinol
      • Reference range is 20-60 mcg/dL.
      • A toxic vitamin A level is higher than 60-100 mcg/dL. Obtain a CBC to rule out leukopenia. Perform calcium, glucose, and liver function tests (LFTs).
      • Levels are affected by liver stores and dietary intake of vitamin A.
    • Serum carotene
      • Normal range is 50-300 mcg/dL.
      • Reflects dietary intake of vitamin A.
  • Vitamin D
    • Obtaining calcium levels is mandatory; they are usually above 11 mg/dL but may be much higher. Phosphate levels may increase with calcium.
    • Renal function tests (ie, BUN, creatine, urinalysis [UA]) are necessary to rule out possible kidney damage from hypercalciuria.
  • Vitamin E: Measure PT, aPTT, and bleeding times, especially if any evidence of bruising or bleeding is present. Platelet aggregation studies may be performed if bleeding time results are abnormal.
  • Vitamin K: Measure PT if the patient is taking oral anticoagulants.
  • Vitamins B-1, B-2, and B-12 require no specific laboratory tests.
  • Vitamin B-3 (ie, niacin)
    • Perform LFTs.
    • Uric acid may be increased, leading to gouty arthritis.
    • Glucose level is occasionally elevated.
  • Vitamin B-6
    • Vitamin B-6 toxicity does not require laboratory or other tests.
    • Lumbar puncture (LP) may be considered to rule out other causes if the patient has a peripheral neuropathy.
  • Vitamin C
    • Perform UAs to rule out uricosuria. False-negative test results for glucosuria are possible.
    • Perform renal function tests. Measure PT if the patient is taking warfarin (Coumadin); vitamin C may interfere with Coumadin.
    • Measure serum iron levels because vitamin C also enhances the absorption of iron.

Imaging Studies

  • Obtain skeletal radiographs to look for calcifications in chronic vitamin A and vitamin D toxicity.
  • Obtain a helical CT scan or an intravenous urogram (IVU) for suspected nephrolithiasis (ie, oxalate stones) in patients with vitamin C toxicity.
  • A kidneys, ureters, bladder (KUB) film is indicated for suspected toxicity from iron-containing pills.

Other Tests

  • Obtain an ECG to evaluate for effects of hypercalcemia in patients with vitamin D toxicity.

Procedures

  • An LP may be indicated to rule out increased intracranial pressure (ICP) in patients with vitamin A toxicity.

More on Toxicity, Vitamin

Overview: Toxicity, Vitamin
Differential Diagnoses & Workup: Toxicity, Vitamin
Treatment & Medication: Toxicity, Vitamin
Follow-up: Toxicity, Vitamin
References
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References

  1. North America, Asia lead vitamin and supplement usage. Nielsen Wire. Available at http://blog.nielsen.com/nielsenwire/consumer/north-america-asia-lead-vitamin-and-supplement-usage/. Accessed March 20, 2009.

  2. Griffin RM, Hoffman H. Live well vitamins & supplements center. WebMD. Available at http://gnc.webmd.com/vitamin-facts. Accessed March 22, 2009.

  3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline]. [Full Text].

  4. Dietary Supplement Fact Sheet: Vitamin A and Carotenoids. National Institutes of Health - Office of Dietary Supplements. Available at http://ods.od.nih.gov/factsheets/vitamina.asp. Accessed July 5, 2007.

  5. Pazirandeh S, Burns DL. Overview of vitamin A. UpToDate. Available at www.uptodate.com. Accessed July 5, 2007.

  6. Bakerman S. ABC's of Interpretive Laboratory Data. 4th ed. Scottsdale, AZ: Interpretive Laboratory Data, Inc; 2002.

  7. Brody JE. In vitamin mania, millions take a gamble on health. In: New York Times. October 26, 1997:1, 20.

  8. Cristoph RA. Vitamins. In: Manual of Toxicologic Emergencies. Year Book Medical Publishers; 1989:490-5.

  9. Dietary Supplement Fact Sheet: Vitamin E. National Institutes of Health - Office of Dietary Supplements. Available at http://ods.od.nih.gov/factsheets/vitamine.asp. Accessed March 20, 2009.

  10. Fischbach F. A Manual of Laboratory and Diagnostic Tests. 7th ed. Lippincott Williams & Wilkins; 2004.

  11. Food and Nutrition Board. Recommended Dietary Allowances. 10th ed. National Academy Press: Washington, DC; 1989.

  12. Goldfrank L, Lewis R. Vitamins. In: Goldfrank's Toxicologic Emergencies. 5th ed. Prentice Hall; 1994:535-44.

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

  14. Hoffman RS. Thiamine hydrochloride. In: Goldfrank L, ed. Goldfrank's Toxicologic Emergencies. 5th ed. New York: Prentice Hall; 1997:825-6.

  15. Med Lett Drugs Ther. Toxic effects of vitamin overdosage. Med Lett Drugs Ther. Aug 3 1984;26(667):73-4. [Medline].

  16. Meyers DG, Maloley PA, Weeks D. Safety of antioxidant vitamins. Arch Intern Med. May 13 1996;156(9):925-35. [Medline].

  17. NIH Clinical Center. Vitamin E. National Institutes of Health - Office of Dietary Supplements. Available at http://ods.od.nih.gov/factsheets/vitamine.asp. Accessed July 5, 2007.

  18. Sachter JJ. Vitamins. In: Handbook of Medical Toxicology. Little Brown & Co Inc; 1993:399-402.

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Further Reading

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Keywords

vitamin A, retinol, vitamin D, cholecalciferol, vitamin E, alpha-tocopherol, vitamin K, phytonadione, vitamin B-1, thiamine, vitamin B-2, riboflavin, vitamin B-3, niacin, vitamin B-6, pyridoxine, vitamin B-12, cyanocobalamin, vitamin C, ascorbic acid, folic acid, B complex vitamins, nicotinic acid, beta-carotene, provitamin A, vitamin K-3, menadione, vitamin toxicity, iron-containing vitamins, fat-soluble vitamins, multiple vitamins, acute vitamin overdose, chronic vitamin overdose, craniotabes, bulging fontanelle, osteoporosis, angular cheilitis, alopecia, epiphyseal capping, premature epiphyseal closure, frontal headache, blurred vision, papilledema, hepatomegaly, ascites, erythematous dermatitis, migratory arthritis, increased bone resorption, bone pain, calcinosis, hypercalcemia, jaundice, hemolytic anemia, hyperbilirubinemia, sensory neuropathies, burning pains, paresthesias, ataxia, paralysis, perioral numbness, sensory ataxias, nephrolithiasis, renal colic, occult rectal bleeding, dental decalcification, diminished tendon reflexes, impairment of position sense, impairment of vibration sense

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Contributor Information and Disclosures

Author

Mark Rosenbloom, MD, MBA, FACEP, Adjunct Associate Professor of Medicine, Northwestern University Feinberg School of Medicine; Chief Executive Officer and Editorial Director, PEPID, LLC; Founder and Chairman, The Unicorn Children's Foundation
Mark Rosenbloom, MD, MBA, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Sports Medicine, American Medical Association, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard Lavely, MD, JD, MS, MPH, Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine
Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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