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Case Study: Hypervitaminosis A - Report of a Case in an Adult (1944)

This case study is a great example of the Duration Paradox Rule in action.

The Duration Paradox rule basically states that any condition that Poison/"Vitamin A" seems to help (suppress) early on, will be completely caused/ruined by the continued use of Poison/"Vitamin A".

There is also what I call the Poison/"Vitamin A" "Double-Down" mistake.  This is where people feel that when their initial benefit from Poison/"Vitamin A" wears off and then seems to worsen...rather than figure out they are being poisoned, they decide to take EVEN MORE.  As you can guess, they get benefit for a short time, and then this quickly leads to DISASTER later.

You don't have to believe me, I will show you through this 70+ year old case study.  Things are still the same.  I will comment through the case study.

Although there has been a steady increase in the number of reports of clinical hypervitaminosis A occurring in children since the condition was first described in a child by Josephs, in 1944, only four cases of chronic hypervitaminosis A have been reported in adults. The present report describes chronic hypervitaminosis A occurring in a young adult woman.

If it was "steadily increasing" back in 1944...do you think it could be at epidemic proportions today?

A 21-year-old woman was first seen on July 24, 1954, because of pain in both legs and ankles that had persisted for one week. Increasing fatigue and insomnia had been present for approximately two months. She had had intermittent low back ache and mild bilateral hip pain for one month. There were complaints of occasional aching pain in the left elbow and intermittent severe aching pain in the left foot, which at times made walking difficult. Slight swelling of both ankles and a bluish discoloration on the outer aspect of the right ankle, without a history of trauma, were known for one week. Twice in the preceding two months she had a sore mouth, with small blisters on the sides of the tongue. Frequency of urination had been present for one week. Her appetite had remained good, there was no weight loss, and the menstrual cycle was not altered.

The next part is important.  The following history of problems that they are about to describe, in my opinion, were probably related to her already being Poison/"Vitamin A" toxic.  This also relates to the acne.

Review of her history revealed that her left ovary was removed when she was 18 months of age; the diagnosis had been "fibrous tumor." When she was 19 years of age an intracanalicular fibroadenoma had been removed from the left breast. She had a hymenotomy in May, 1954, for congenital hymenal stenosis. She gave a six-year history of moderately severe acne of the face and upper thorax, treated at various times with diet, lotions, x-ray, and vitamins. Her family history revealed that she was an only child. Her parents were living and well.

Note "diet", "lotions" and "vitamins".  Could the diets tried have contained high Poison/"Vitamin A" foods?  Many lotions and cosmetic products are full of Poison/"Vitamin A" (unrefined shea butter, a fave of the natural skincare industry, is teeming with carotenoids, for example).  The term "vitamins" back then could have easily included cod liver oil.  Lots of unknowns here, and I see these types of things in the histories of my clients/patients every day.

On further questioning it was learned that the patient had taken multiple-vitamin capsules for acne from March to July, 1953, by prescription from a dermatologist. The capsules were taken three times a day, and each capsule contained 10,000 units of vitamin A. Vitamins were also administered intramuscularly on several occasions during this period. There was apparent improvement in the condition with this treatment.

Improvement, you say?  I'm not surprised.  I can tell you what happens later.  This is the Duration Paradox Rule in action that you're about to watch.

With exacerbation of the acne in December, 1953,

Exacerbation, you say?  It's like I knew this was coming!  Then, watch for the "Double Down".

she resumed the use of vitamin A without consulting the dermatologist. She purchased, without prescription, vitamin A capsules that contained 50,000 units per capsule and faithfully took one capsule three times a day. This vitamin intake was supplemented with multiple-vitamin capsules that contained 10,000 units of vitamin A per capsule, and she took from one to three of these each day. This schedule was maintained without interruption from December, 1953, until July 21, 1954. During this period of high vitamin A intake she noted that her hair became less oily but was not difficult to manage. Her nails seemed stronger.

The above improvements would be the last ones before the real disaster starts settling in.  The acne, and everything else, is about to get much worse.

Her skin was not odoriferous but recently became more oily, and there was desquamation of skin around the acne eruptions. On physical examination the patient was an alert, cooperative, intelligent woman, 5 ft. 3 in. ( 160 cm. ) tall and weighing 100 lb. (45.4 kg.). She did not appear ill. The blood pressure was 110/70 mm. Hg, pulse 76 per minute, and respirations 20 per minute. Acneform eruptions were noted on the face and upper thorax. There was desquamation about some of the lesions. The skin was otherwise normal. The distribution and texture of her hair were normal. The fingernails were normal. The examination of ears, eyes, nose, mouth, and pharynx was not remarkable. The thyroid gland was not palpable. No masses were felt in the breasts. The lungs were clear to auscultation and percussion, and the heart was normal. Her abdomen was soft and flat. The liver edge was palpated 3.5 cm. below the right costal margin in the midclavicular line on deep inspiration and was not tender. No other organs or masses were felt. Skeletal examination revealed a mild dorsolumbar scoliosis centered at T-10. There was moderate tenderness on percussion over both tibias. There was no tenderness on percussion over the other long bones or the vertebral spines. A yellow-green discoloration of the skin, approximately 4 cm. in diameter, was noted anterior to the lateral malleolus of the right ankle. There was no pretibial or ankle edema. The rectal examination was normal. X-ray examination of the long bones revealed no abnormalities. There was no roentgenologic evidence of periostitis. Laboratory studies on July 26, 1954, were as follows: hemoglobin value 14.6 gm. per 100 cc, red blood cell count 4,450,000 per cubic millimeter, white blood cell count 7,550 per cubic millimeter, polymorphonuclear leukocytes 67%, lymphocytes 29%, monocytes 2%, eosinophils 1%, basophils 1%, serum albumin 4.92 gm. per 100 cc, serum globulin 1.88 gm. per 100 cc, serum alkaline phosphatase 2.2 King and Armstrong units, direct serum bilirubin 0.2 mg. per 100 cc, indirect 0.6 mg. per 100 cc, prothrombin time 14.9 seconds (control 15 seconds), thymol turbidity 1 unit, cephalin flocculation 2+ in 48 hours, total serum lipids 802 mg. per 100 cc. ( normal range 385-675 mg. per 100 cc), serum carotene 151 meg. per 100 cc. (normal range 80-370 meg. per 100 cc. ), and serum vitamin A alcohol 832 meg. per 100 cc. (normal range 15-60 meg. per 100 cc.). Studies on Sept. 22, 1954, revealed a serum carotene level of 179 meg. per 100 cc and a serum vitamin-A-alcohol level of 50 meg. per 100 cc.

Note that there are two Vitamin A blood tests there.  Note that the second one is still definitely on the high-normal side.  Her problems are not over.

All blood samples were obtained with the patient in the fasting state. Three days before she consulted us she had exhausted her supply of vitamin A capsules. With discontinuation of the vitamin A capsules and withdrawal of the multivitamins, no further treatment was indicated. One week after the initial examination all leg and ankle pain had subsided and the tibial tenderness had disappeared completely. The liver edge could still be palpated 1.5 cm. below the right costal margin on deep inspiration. Two weeks after the initial examination there were no subjective complaints and the liver edge was no longer palpable. The acneform lesions persisted. One year later she was free of subjective complaints and physical examination was within normal limits.

She still has the acne.  She is still toxic.

Comment
The administration of vitamin A in a dose of 50,000 units three times a day has been cited as a useful adjuvant in the treatment of acne vulgaris when the nature of the lesions suggests vitamin A deficiency.

The "Double Down".  Synthetic retinoids (Retin-A and Accutane) do this too, and are even more toxic to the system.  My Detox Program can help repair that damage too.

 In the case presented this approximate dosage schedule was maintained for over seven months, and vitamin A intoxication resulted. The size and duration of the dose that will produce toxic effects in an adult and the incidence and severity of these effects will vary with the person.

There is absolutely an individuality to the rate at which one gets poisoned with this stuff.

The physician administering large doses of vitamin A over a long period of time should be acquainted with the possible manifestations of intoxication. In all four of the previously reported cases of chronic hypervitaminosis A in adults, loss of hair, bone and joint pains, advanced skin changes, and bone tenderness were described.

Hey, do you have or know anyone who is:

  • Losing their hair?  Hair thinning?
  • Experiencing joint pains?
  • Having skin problems, ranging anywhere from dry skin to eczema to cracked heels to seborrhea?

This is a real epidemic these days, folks.  Don't forget the insomnia and fatigue from the very start of the case study!  More potential symptoms below:

There was no loss of hair in our patient, and toxic skin manifestations were minimal. Bone and joint pains and bone tenderness were present. Three of the four case reports described symptoms of anorexia, weight loss, and weakness, none of which were noted by our patient. Polyuria [having to pee frequently], soreness of the mouth and lips, pruritus [itching], exophthalmos, severe headaches, and hepatomegaly have each been reported in two cases. In the case described by Gerber and co-workers, the hepatomegaly disappeared in the latter years of the illness in spite of continued excessive intake of vitamin A. In our case, frequency of urination, soreness of the mouth, blisters on the tongue, and hepatomegaly were present, but there were no complaints of headache or pruritus, and exophthalmos was not present. Insomnia, night sweats, change in the menstrual cycle, polydipsia [increased thirst], splenomegaly, hemorrhagic manifestations [easy bruising would be an early/mild stage], and x-ray evidence of bone involvements have each been described in one case. Of this group our patient complained only of insomnia. There was an unexplained ecchymosis [bruise, see earlier comment about bruising] on the right ankle, but no bleeding tendency was demonstrated, and the prothrombin time was normal. The spleen was not palpable, and x-ray studies of the long bones were interpreted as normal.

Just as it takes different amounts to make different people toxic, different people will also have different symptoms once they are toxic.

The fasting vitamin A blood level of 832 meg. per 100 cc. reported in our patient is one of the highest ever recorded. There was a moderate increase in total serum lipids. A similar elevation was found in the case in an adult reported by Sulzberger, whereas Gerber's patient had a normal total lipid level in the latter years of her illness. Josephs ' observed an early rise in serum lipids, with a return to normal later in the course of the illness. An elevated alkaline phosphatase level has been recorded in only one adult patient. Abnormalities in serum protein and prothrombin time have not been recorded in adults. These determinations were normal in our patient.

Summary
A 21-year-old woman with chronic hypervitaminosis A had ingested 160,000 to 180,000 units of vitamin A daily for over seven months in a program of self-medication for acne. She gave a history of bone and joint pain, fatigue and insomnia, swelling of the ankles, ecchymosis, soreness of the mouth with blisters on the tongue, and frequency of urination. Positive physical findings included acne, hepatomegaly, tibial tenderness, and ecchymosis on the right ankle. X-ray studies of the long bones were normal. Fasting blood studies helped confirm the diagnosis. The symptoms and signs disappeared promptly after discontinuation of the vitamin A medication, and the serum vitamin A alcohol level returned to normal.

My final comment on this case study is that if one has a "normal" serum Vitamin A, aka retinol, aka Poison/"Vitamin A" blood test level, then they are already running a toxicity.  It has been shown in multiple studies that one can have a "normal" serum level and be getting completely toxic in their liver and elsewhere.

Dr. Garrett Smith, the "Nutrition Detective"
Licensed Naturopathic Physician (NMD) in Arizona
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