Unrecognised severe vitamin D deficiency

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Abstract
Vitamin D deficiency remains common and may mimic other musculoskeletal disorders or mental health problems Since Glisson gave the first authoritative description of rickets in 1650 and McCollum and coworkers described its cause as vitamin D deficiency in 1922,1 clinical descriptions of hypovitaminosis D have become more variable, making the condition less recognisable.2 At the same time, the condition remains highly prevalent world wide, yet is preventable.3 We present two cases of longstanding undiagnosed severe vitamin D deficiency with important clinical consequences. ### Case 1 A 53 year old woman of Pakistani origin underwent mastectomy for invasive ductal carcinoma of the right breast with adjuvant radiotherapy and tamoxifen treatment. Over the next two years she presented at her follow-up appointments with migratory musculoskeletal pains, including pain in the right arm, loin, right posterior chest with bony tenderness and whole body discomfort. A chest x ray showed an irregularity of the upper cortex of the right posterolateral seventh rib. An isotope bone scan showed multiple areas of increased radionuclide uptake in the ribs and left sacroiliac joint. We made a working diagnosis of metastatic bone disease and started the aromatase inhibitor anastrazole and the oral bisphosphonate sodium clodronate. Over the next six months her pains worsened, and areas of tenderness in the arms, legs, ribs, and left sacroiliac joint were poorly controlled by cocodamol. A repeat bone scan showed no change (fig 1)⇓. A poor prognosis was given and combination chemotherapy (adriamycin, taxotene) was planned, but first she took a six week summer trip to Pakistan to visit family. On her return to the United Kingdom, her symptoms had completely resolved. A whole body computed tomography scan showed a pelvic stress fracture but no evidence of visceral metastasis. Chemotherapy was delayed. Fig 1 Tc 99m HDP bone scanbefore rescue …