Vitamin D deficiency and cardiac failure in infancy.

A girl aged 412 months was referred in shock with acute heart failure and respiratory distress. She was of West African descent but had been born in the UK and breastfed from birth. Echocardiogram revealed a poorly functioning dilated heart (fractional shortening 6.5%; Table 1). She was admitted to the paediatric intensive-care unit where treatment included inotropic agents, furosemide and captopril. Intravenous antibiotics were also administered for suspected chest infection. Laboratory investigations revealed a severe normocytic anaemia (haemoglobin 6.8 g/dL), abnormal clotting (international normalized ratio 2.04) and a blood picture typical of vitamin D deficiency (low calcium [1.37 mmol/L], low phosphate, low vitamin D, raised parathyroid hormone and raised alkaline phosphatase). Radiographs showed bony changes consistent with rickets. Her dilated cardiomyopathy was therefore attributed to nutritional vitamin D deficiency. In addition to supportive treatment for her cardiac failure and transfusion for the anaemia she received ergocalciferol and Calcium-Sandoz. By day 11 serum calcium was within normal limits (2.52 mmol/L); phosphate remained low. At the time of her discharge on day 17 the echocardiogram showed persisting left ventricular dilatation, although ventricular function was improving (fractional shortening 17.8%). Subsequently all her biochemical results became normal, and fifteen months after discharge her left ventricular dilatation had completely resolved (fractional shortening 34%). She is now well without medication. Case 2