Cause of coma in a #woman surprised us! 1. 65-year old woman was brought in an #unconscious state to #emergency dept. She sounded normal over phone to her son about 24 hours earlier. She stayed alone, so, further details were not available. #MedTwitter #internalmedicine

2. Clinical examination revealed an #unconscious patient. She was afebrile; pulse and BP were normal. Pupils were equal and reacting to light. Meningeal signs were absent. She was electively mechanically ventilated in view of her unconscious state.

3. Serum #calcium was high (13 mg/dL). MRI brain was normal. Lumbar puncture was normal. Investigations were done to determine the cause of high calcium. There was no evidence of #endocrine disorder, infection or #Cancer. #VitaminD level was very high (160 ng/mL).

4. We asked her son to check at home if she was taking any medicines. He brought empty strips of vitamin D tablets. She had taken high dose vitamin D tablets for at least 40 days. Final diagnosis was vitamin D #toxicity (VDT) causing coma. First time we had ever seen this!

5. She was appropriately treated. She responded well to treatment. Ventilator was removed in 2 days, and she was discharged after 5 days. However, blood calcium levels took several months to normalize.

5. Vitamin D is fat soluble; and it gets stored in liver & adipose tissue. High doses of vitamin D can cause toxicity. Common symptoms include lethargy, tiredness, dizziness, confusion, irritability, abdominal pain and vomiting. #Seizures and coma occur in severe cases.

6. Take home message a. Vitamin D has many benefits and deficiency should be treated. b. People with normal Vitamin D or with mild deficiency, should not receive high dose or long duration vitamin D supplements. c. Early recognition & treatment is vital for good outcome in VDT.