Rampant rickets: an old foe re-emerges
A 7 month old boy presented via the Paediatric Emergency Department with a 3 week history of intermittent “stiff hands and feet”. In the preceding 24 hours the symptoms were permanent and distressing. He was the only child of a non- consanguineous Asian marriage. He was an assisted vaginal delivery at term, requiring postnatal antibiotics for sepsis. He has since been neuro-developmentally normal with no other medical history. He is exclusively breast fed and weaning to solids. Examination revealed symmetrical and bilateral flexion of the wrists and MCP joints. Passive extension was possible and his toes were clawed. He demonstrated wrist joint swelling bilaterally. No other rachitic findings were obvious
A clinical diagnosis was made of carpo-pedal spasm secondary to hypocalcaemia.
Blood results showed WCC 3.5, lymphocytes 1.83, ALP 837, corrected calcium 1.24, phosphate 1.6, PTH 370, TSH 2.9, fT4 27.
Chest and wrist xrays demonstrated classical rachitic changes.
Treatment was commenced with oral colecalciferol, multi-vitamins, calcium supplements and iron supplements. The child improved immediately both biochemically and clinically. He was discharged with outpatient follow up.
Serum vitamin D level was 5.8 ng/L confirming Vitamin D deficient rickets..
Conclusions Rickets, previously recognised as a disease of the industrial revolution and developing world, is re-emerging as a significant cause of morbidity in children in the UK.
Most commonly the cause is dietary and associated with vitamin D deficiency. The risk factors are multi-factorial such as maternal vitamin D deficiency, prolonged breast feeding, decreased exposure to UV light, pigmented skin and low calcium diets.
Aside from the classical skeletal changes, developmental delay, neuromuscular symptoms and cognitive changes are increasingly recognised.
The treatment is vitamin D but at what dose?