A 58- year-old female presented with vomiting, dizziness, and a blood pressure of 80/60 mmHg. Laboratory: serum creatinine 3.1 mg/dl (baseline 1 mg/dl), BUN 34 mg/dl (baseline 10 mg/dl), corrected calcium 12.3 mg/dl, low PTH , normal 25-OH vitamin D, and normal PTH-related protein. Two months prior, serum calcium was normal and 25-OH vitamin D was low. Serum immunofixation showed a nonspecific pattern- monoclonal gammopathy could not be ruled out. Skeletal survey was negative. Hypotension, acute kidney injury and hypercalcemia were corrected with the administration of IV fluids. The patient was not able to have her medications brought to the hospital for reconciliation until the day of discharge. Reconciliation revealed she was taking calcitriol 0.5 mcg daily. Outpatient record review revealed that the resident had ordered the calcitriol in error. He cancelled it, but after having signed it, so it was transmitted to the pharmacy. He failed to communicate this to the receiving pharmacy. Therefore, the patient received the drug.
Discussion:
Vitamin D intoxication generally occurs after inappropriate use of vitamin D preparations. Case reports have described hypervitaminosis D due to errors in manufacturing, formulation or prescription, including milk excessively fortified with vitamin D. The patient remained normocalcemic after discharge, suggesting the monoclonal gammopathy was an unlikely contributing factor to the hypercalcemia. We feel that the cause of the hypercalcemia was the erroneous use of calcitriol, a highly potent 1,25-hydroxyvitamin D analog.
Conclusions:
This case emphasizes the need for medication reconciliation early in the hospital course and communication with the pharmacy if an electronic health records medication order is cancelled after it is electronically signed.