Vitamin D Deficiency Rickets and COVID-19 Pandemic
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An 18-month-old male infant with dark skin pigmentation presented with bowlegs in late December 2020. He was from a low-income family and lived in flats in an urban city. Since the child started walking, his mother had concerns about his bowlegs. However, she was late in seeking medical attention due to strict lockdown measures in the country. She was a homemaker, rarely went outdoors, and never consumed vitamin D supplements. The child was born at term and was exclusively breastfed until six months of age. His diet was lacking in nutrients. A 7-day food frequency assessment showed inadequate vitamin D intake. He was not given fish, rarely received fortified food or milk, and was continued to be breastfed. Moreover, the child was confined to the house from mid-March 2020, since the lockdown.

The child's development milestones were normal, and anthropometric parameters were within normal limits (weight, 10.2kg (median and -1SD); occipitofrontal diameter, 43cm (-2SD and -3SD); length, 73cm (-2SD and -3SD)). His length was within the mid parental height range. He was alert and playful. Several bone deformities were noted: Harrison sulcus, widened wrists and ankles, and curved legs. His head shape and spine were normal.

The results of laboratory analysis of blood were as follows: serum-corrected calcium, 2.48mmol/L; phosphorus, 3.2mg/dL; alkaline phosphatase, 863.9U/L; 25-OH-vitamin D, 8ng/mL. The serum parathyroid hormone (PTH) level was high. The liver enzyme (aspartate transaminase, alanine transaminase, and gamma-glutamyl transpeptidase) levels and renal function test results were within normal limits. The mother's serum 25-OH-vitamin D level was 12.4ng/mL, and the PTH level was 174.9pg/mL.

Furthermore, the child showed evidence of iron deficiency. A complete blood count revealed the following: white blood cell count, 12.02×109/L, hemoglobin, 11.3g/dL; mean cell volume, 70.3fL; mean cell hemoglobin, 23.4 pg; mean cell hemoglobin concentration, 33.3g/dL; platelet count, 523×109/L; and red cell distribution width, 17.1%. A blood picture suggested iron deficiency. He had low iron stores. Radiological evaluation revealed cupping, fraying, and widening of the distal ends of the radii, distal and proximal ends of the tibiae and fibulae, and distal ends of the femurs. The diagnoses of vitamin D deficiency rickets and iron deficiency were confirmed based on clinical, biochemical, and radiological evidence. The child was administered 2000 IU of cholecalciferol, 500mg of oral calcium, and 60mg of iron sulfate. The mother was referred to an endocrinologist and administered vitamin D and calcium therapy.