Unrecognised severe vitamin D deficiency

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.