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Vitamin Toxicity Workup

  • Author: Mark Rosenbloom, MD, MBA; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Dec 05, 2015
 

Approach Considerations

Acetaminophen and aspirin levels should be assessed in every suspected ingestion. Electrolyte levels must be assessed in patients with severe vomiting or diarrhea.

In addition to laboratory studies, imaging and electrocardiographic studies can be used in the assessment of patients with vitamin toxicity.

Imaging Studies

Imaging studies can be employed as follows:

  • Skeletal radiography - For calcifications in chronic vitamin A and vitamin D toxicity
  • Hand radiography - For periosteal calcifications
  • Helical computed tomography (CT) scanning and urography - Obtain a helical CT scan or an intravenous urogram (IVU) for suspected nephrolithiasis (ie, oxalate stones) in patients with vitamin C toxicity
  • CT scanning of the brain - In the presence of neurologic abnormalities, perform a CT scan of the brain, without contrast, only if the prothrombin time (PT) is significantly prolonged and the patient has either a decreased level of consciousness or a focal neurologic deficit
  • Kidneys, ureters, bladder (KUB) film - Indicated for suspected toxicity from iron-containing pills
  • Bone mineral density testing - to evaluate the effect of long-term vitamin A intoxication on reducing bone density and causing osteoporosis [43]

Electrocardiography

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

Next

Laboratory Studies

Vitamin A

The reference range for vitamin A is 20-60 mcg/dL, and a toxic level is higher than 60-100 mcg/dL. Obtain a complete blood count (CBC) to rule out leukopenia. Also perform calcium, glucose, and liver function tests (LFTs). levels are affected by liver stores and dietary intake of vitamin A.

For serum carotene, the normal range is 50-300 mcg/dL. Carotene levels reflects dietary intake of vitamin A.

Laboratory studies in vitamin A toxicity include the following:

  • Serum electrolytes - If vomiting or diarrhea is present
  • Serum calcium - Hypercalcemia may be observed [44]
  • Liver function tests (LFTs)
  • Complete blood count (CBC) - For anemia, leukopenia, or thrombocytopenia
  • Vitamin A assessment by serum retinol concentrations - Vitamin A assessment by serum retinol concentrations may be helpful if the level is markedly high; in mild conditions, however, it may not be sensitive
  • High-performance liquid chromatography (HPLC)

Johnson-Davis et al reported that a modified form of HPLC they developed shortened analysis time for serum concentrations of vitamins A and E.[45] Using their modifications—a high-throughput analytic column and small diameter tubing—to determine pediatric reference intervals for the 2 vitamins in 1136 healthy children, the authors found that their technique reduced run-time by 60%, mobile phase consumption by 39%, and sample injection volume by 50%.

A lumbar puncture may be indicated to rule out increased intracranial pressure in patients with vitamin A toxicity.

Vitamins B-1, B-2, and B-12

These require no specific laboratory tests for these vitamins.

Vitamin B-3

Perform LFTs. Uric acid may be increased, leading to gouty arthritis. The glucose level is occasionally elevated.

Vitamin B-6

Vitamin B-6 toxicity does not require laboratory or other tests. Lumbar puncture may be considered to rule out other causes if the patient has a peripheral neuropathy.

Vitamin C

Perform urinalysis to rule out uricosuria. False-negative test results for glucosuria are possible. Also perform renal function tests.

Measure PT if the patient is taking warfarin (Coumadin), since vitamin C may interfere with this drug. Serum iron levels should also be measured, because vitamin C enhances iron absorption.

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, blood urea nitrogen [BUN] and creatine tests, as well as urinalysis) are necessary to rule out possible kidney damage from hypercalciuria.

Vitamin E

Measure PT, activated partial thromboplastin time (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.

Monitor PT in patients who are taking anticoagulants concurrently with vitamin E or in patients suggested to have vitamin K deficiency while taking vitamin E, because the PT may be elevated.

The plasma concentration of alpha tocopherol (normal, 6-14 mcg/mL) can be measured to confirm that high levels of vitamin E are in the blood.

Vitamin K

Measure PT if the patient is taking oral anticoagulants.

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Contributor Information and Disclosures
Author

Mark Rosenbloom, MD, MBA Chief Executive Officer and Editorial Director, PEPID, LLC; Founder and Chairman, The Unicorn Children's Foundation; Chief Medical Officer, LIFEFORCE Medical Institute

Mark Rosenbloom, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, Royal Society of Medicine, American Academy of Anti-Aging Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Angela Gentili, MD Director of Geriatric Medicine Fellowship Program, Professor of Internal Medicine, Division of Geriatric Medicine, Virginia Commonwealth University Health System and McGuire Veterans Affairs Medical Center, Richmond, VA

Angela Gentili, MD is a member of the following medical societies: Virginia Geriatrics Society, American Geriatrics Society

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Acknowledgements

Robert A Adler, MD Chief of Endocrinology and Metabolism, McGuire Veterans Affairs Medical Center; Professor, Departments of Internal Medicine and Epidemiology and Community Health, Virginia Commonwealth University

Robert A Adler, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Bone and Mineral Research, and Endocrine Society

Disclosure: Eli Lilly Grant/research funds Independent contractor; Genentech Grant/research funds Independent contractor

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.

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, InternationalSocietyfor Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine, Excela Health System

Disclosure: Nothing to disclose.

Christy L Henry, MD

Disclosure: Nothing to disclose.

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, and Endocrine Society

Disclosure: Nothing to disclose.

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.

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.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and 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.

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