Images in pediatric endocrinology: vitamin D deficiency rickets and other nutritional deficiencies in a 12-month-old infant.

A girl of Indian ethnicity, born in Australia at term, presented at 12 months of age with irritability, failure to thrive, reluctance to weight bear and hypocalcemia. Her weight had decreased from the 25th to the 3rd percentile over 7 months. Her dietary intake had been predominantly breast and cow ’ s milk. Clinically, she had tender, widened wrists (Figure 1 ). Blood tests were consistent with severe vitamin D defi ciency: corrected calcium, 1.72 mmol/L (normal range 2.25 – 2.75 mmol/L); phosphate, 1.4 mmol/L (1.2 – 2.4 mmol/L); alkaline phosphatase, 1094 U/L (60 – 300 U/L); 25-hydroxy vitamin D, 11.2 nmol/L (50 – 150 nmol/L); and parathyroid hormone, 108 pmol/L (1 – 7 pmol/L). She had concomitant iron and vitamin B12 defi ciencies: ferritin, 22 μ g/L (30 – 150 μ g/L) and vitamin B12 10 pmol/L (>35 pmol/L). The radiological appearance of her wrists and knees was consistent with rickets (Figure 2 ).