Jan 092015
 
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Gastric_smallLet’s hope you never find yourself in this kind of trouble. This is the story of a most unfortunate lady, age 64. She had undergone gastric bypass at age 58 and had lost 100 pounds yet remained severely obese. She presented with diffuse muscle and bone pain, pain she had experienced for several years and varied in intensity from day to day. The pain was especially pronounced in her rib cage. All of this was very concerning because she had breast cancer one year after her gastric bypass and soon thereafter underwent a modified radical mastectomy. The worry now was that her pain was from metastatic cancer to the bone. “A bone scan, obtained because of concern about metastatic malignancy, revealed areas of increased activity in the right hip, the right inferior pubic ramus, and multiple left ribs, interpreted as consistent with metastases.” Also worrisome was an elevated alkaline phosphatase of 231 (normal range is 39–117), an elevation that can occur with a serious, active disease process involving the bone. Things would change for this lady and fears would subside.Appropriate labs were drawn. As a result, her vitamin D level was found to be “undetectable” and her PTH level was significantly elevated, presumably in response. She was started on high-dose vitamin D along with calcium supplementation. After three months of treatment her rib painresolved and remained resolved when reevaluated four months later. The resolution of her rib pain occurred even though her vitamin D status still remained low at 15 ng/ml.

Comment: Gastric bypass is a “red flag” when it comes to an individual’s vitamin D status. This procedure purposefully limits the intake and absorption of food and nutrients in order to promote weight loss. Accordingly, the amount of vitamin D absorbed from food sources is greatly decreased following gastric bypass. This is, undoubtedly, the reason why her vitamin D status became so severely compromised. Two things in particular make this case noteworthy. First, she had a fairly rapid turnaround in her symptoms following vitamin D replacement. And, second, this case of vitamin D deficiency masqueraded as metastatic bone cancer. This individual still has health challenges to face but has been relieved of one very serious concern, that of bone cancer. Bone cancer is an extremely serious matter. But then, so is hypovitaminosis D. The reference below presents three similar case reports of vitamin D deficiency masquerading as metastatic cancer.
—Khokhar JS, Brett AS, Desai A 2009 Vitamin D Deficiency Masquerading as Metastatic Cancer: A Case Series. The American Journal of the Medical Sciences; April; 337(4):245–247

© 2014, Eugene L. Heyden, RN
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