Rickets of Vitamin D Deficiency  Tetany of Vitamin D Deficiency <ul><li>MBBS.weebly.com </li></ul>
Rickets
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>Rickets   ---failure in mineralization of  </li></ul><ul><li>growing bone or osteoid tissue (children) </li></ul><...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>* VitD ( Vitamin D )   </li></ul><ul><li>important in mineralization of newly  </li></ul><ul><li>formed osteoid </...
<ul><li>Physiological function of VitD </li></ul><ul><li>* antirachitic function   facilitation   </li></ul><ul><li>intest...
Metabolism and regulation of VitD <ul><li>7-dehydrocholesterol  irradiated ergosterol </li></ul><ul><li>Provitamin   (skin...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>Etiology </li></ul><ul><li>* Inadequate gain  of VitD from mother </li></ul><ul><li>*   Inadequate direct exposure...
<ul><li>Predisposing factors to VitD deficiency  </li></ul><ul><li>disorders interfere with absorption and  </li></ul><ul>...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>normal osteogenesis : cartilagenous </li></ul><ul><li>intramembraneous </li></ul><ul><li>cartilage cells’ normal c...
Fig.1 Levels of growth plate zone of resting cartilage zone of proliferating cartilage zone of calcifying cartilage zone o...
<ul><li>In Ricket  cartilage cells fail to complete their normal </li></ul><ul><li>cycle of proliferation and degeneration...
<ul><li>enlarged costochondral  </li></ul><ul><li>junction </li></ul>*Non-calcified, hypertrophied growth plate in rickets...
Pathology <ul><li>Disturbance of sclerotic calcification </li></ul><ul><li>osteomalacia  (骨质软化)  </li></ul><ul><li>osteoid...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
Pathogenesis <ul><li>can be conceptualized to be  </li></ul><ul><li>the body’s attempt to maintain  </li></ul><ul><li>norm...
<ul><li>VitD deficiency   </li></ul><ul><li>↓ Ca, P absorption from the intestine  </li></ul><ul><li>↓ serum Ca level  </l...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>Clinical manifestations </li></ul><ul><li>Incidental age   3 m-2 yr </li></ul><ul><li>osseous changes in growing b...
Clinical manifestations <ul><li>Stages </li></ul><ul><li>Early stage </li></ul><ul><li>Progressing stage </li></ul><ul><li...
Early stage  (1) <ul><li>Symtoms  <6(3)m  </li></ul><ul><li>nonspecific neuropsychiatic---  </li></ul><ul><li>irritability...
bare occiput
Early stage  (2) <ul><li>biochemical changes </li></ul><ul><li>serum Ca  -> or ↓,  P ↓,  </li></ul><ul><li>ALP (Alkaline p...
Progressing stage <ul><li>*   symptoms in early stage </li></ul><ul><li>*   osseous changes </li></ul><ul><li>*   retardat...
Progressing   stage  osseous change <ul><li>*   Head </li></ul><ul><li>craniotabes( 颅骨软化 )(3~6 m) </li></ul><ul><li>boxlik...
boxlike appearance
Progressing stage  osseous change <ul><li>*   Chest  (about 1yr) </li></ul><ul><li>beading of the ribs (rachitic rosary 佝偻...
rachitic rosary
Harrison groove   Funnel-like chest   L:  pigeon breast
Progressing stage   osseous change <ul><li>*   Extremities  </li></ul><ul><li>*thickening of the wrists and ankles(Fig ) <...
R.  thickening  of the wrists   L.  thickening  of the ankles
Thickening of the wrist Thickening of the ankles
R. bowlegs   L. knock-knees
Progressing   stage  osseous change <ul><li>*   others </li></ul><ul><li>spinal column  (kyphosis 脊柱后突,  s   scoliosis 脊柱侧...
kyphosis  & scoliosis
Progressing stage <ul><li>muscle and ligament </li></ul><ul><li>poorly developed and lack tone </li></ul><ul><li>(late in ...
Clinical manifestations  <ul><li>summarized as following table </li></ul><ul><li>Histological  osteomalacia  osteoid </li>...
Progressing   stage <ul><li>Biochemical changes </li></ul><ul><li>serum Ca↓, P↓,  </li></ul><ul><li>serum ALP (Alkaline ph...
Progressing stage <ul><li>Roentgenographic examination (Fig) </li></ul><ul><li>*   rachitic metaphysis </li></ul><ul><li>(...
Upper limp Normal X rays  Rachitic metaphysis
Lower limp Normal X rays  Rachitic metaphysis
Convalescent stage <ul><li>(after adequate antirachitic treatment) </li></ul><ul><li>*   Clinical manifestation improved--...
Sequelae stage <ul><li>>2-3 yr  </li></ul><ul><li>Severe rachitic child leave osseous deformities </li></ul><ul><li>—  bow...
Sequelae stage
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>based on </li></ul><ul><li>a history of inadequate gain of VitD </li></ul><ul><li>Clinical observation </li></ul><...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>*   Other rickets </li></ul><ul><li># familiar hypophosphatemia  ( 家族性低磷血症) </li></ul><ul><li>or X-linked hypophos...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>* pregnant and lactating mothers  </li></ul><ul><li>adequate sunlight; VitD 800U/d; </li></ul><ul><li>diet rich in...
<ul><li>&  Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and reg...
<ul><li>To  control the progressive stage </li></ul><ul><li>prevent osseous deformity   </li></ul><ul><li>N atural and art...
<ul><li>VitD analogue administration </li></ul><ul><li>Orally  VitD  2,000~4,000 IU/d × 2~4 W </li></ul><ul><li>1,25(OH) 2...
<ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </l...
<ul><li>R achitic tetany </li></ul><ul><li>Incidental age  <6m( 4m-3yr) </li></ul><ul><li>Form of plasma Ca </li></ul>8~10...
<ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </l...
<ul><li>VitD deficiency   </li></ul><ul><li>↓ Ca, P absorption from the intestine  </li></ul><ul><li>↓ serum Ca level  </l...
<ul><li>serum Ca 2+ <0.75~1mmol/L  </li></ul><ul><li>serum Ca<1.75~1.88 mmol/L </li></ul><ul><li>the loss of the inhibitor...
<ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </l...
Prediposing factor <ul><li>VitD deficiency </li></ul><ul><li>accompany with dull parathyroid response </li></ul><ul><li>Re...
<ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </l...
Clinical manifestations <ul><li>tetany and concurrent rickets   </li></ul><ul><li>Manifest Tetany  (serum Ca 2+ <0.75mmol/...
<ul><li>Manifest Tetany   </li></ul><ul><li>Convulsions   brief but recurrent, </li></ul><ul><li>conscious between seizure...
Fig. Carpopedal spasm   The wrist are flexed,  the finger extended,  the thumbs adducted over the palms,  the feet extende...
<ul><li>latent tetany  </li></ul><ul><li>symptoms are not evident, but can be elicited  </li></ul><ul><li>by  ischemia  </...
Latent tetany <ul><li>Chvostek sign   facial spasm  </li></ul><ul><li>tapping anterior to external auditory meatus </li></...
Latent tetany <ul><li>Trousseau sign  carpospasm </li></ul><ul><li>A blood pressure cuff on the arm is inflated  </li></ul...
<ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </l...
<ul><li>bases on </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>manifest tetany, latent tetany </li></ul><ul>...
<ul><li>Afebrile convulsion   </li></ul><ul><li>H ypoglycemia (Glu ↓ ) </li></ul><ul><li>Hypom agnesemia (Mg ↓ ) </li></ul...
<ul><li>Prognosis  </li></ul><ul><li>good unless treatment is delayed,  </li></ul><ul><li>death rarely occurs  </li></ul><...
<ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </l...
<ul><li>Anticonvulsive treatment </li></ul><ul><li>* oxygen  inhalation </li></ul><ul><li>* drugs </li></ul><ul><li>10% Ch...
<ul><li>* Active treatment   — </li></ul><ul><li>↑ serum Ca  >  tetany level </li></ul><ul><li>Calcium gluconate   (10%)  ...
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18 Rickets Of Vitamin D Deficiency,Tetany Of Vitamin D Deficiency

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18 Rickets Of Vitamin D Deficiency,Tetany Of Vitamin D Deficiency

  1. 1. Rickets of Vitamin D Deficiency Tetany of Vitamin D Deficiency <ul><li>MBBS.weebly.com </li></ul>
  2. 2. Rickets
  3. 3. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  4. 4. <ul><li>Rickets ---failure in mineralization of </li></ul><ul><li>growing bone or osteoid tissue (children) </li></ul><ul><li>the end of long bone, shaft </li></ul><ul><li>Osteomalacia --mature bone (adults) </li></ul><ul><li>Rickets of Vitamin D deficiency --- </li></ul><ul><li>chronic systemic nutrition-deficient disease </li></ul><ul><li>(<2y) </li></ul>
  5. 5. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  6. 6. <ul><li>* VitD ( Vitamin D ) </li></ul><ul><li>important in mineralization of newly </li></ul><ul><li>formed osteoid </li></ul><ul><li>* PTH ( parathormone ,甲状旁腺素) </li></ul><ul><li>* CT ( calcitonine, 降钙素) </li></ul>Factors associated with Ca ,P metabolism and bone development
  7. 7. <ul><li>Physiological function of VitD </li></ul><ul><li>* antirachitic function facilitation </li></ul><ul><li>intestinal absorption of Ca , P(CaBP) </li></ul><ul><li>reabsorption of Ca & P in the kidneys </li></ul><ul><li>direct effect on mineral metabolism of bone </li></ul><ul><li>(deposition and reabsorption) </li></ul><ul><li>* nonantirachitic function </li></ul><ul><li>cell proliferation, differenciation, immunity </li></ul>
  8. 8. Metabolism and regulation of VitD <ul><li>7-dehydrocholesterol irradiated ergosterol </li></ul><ul><li>Provitamin (skin) (plant) </li></ul><ul><li>photochemically activation </li></ul><ul><li>diet cholecalciferol calciferol </li></ul><ul><li>(VitD 3 ) (VitD 2 ) </li></ul><ul><li>25-hydroxylase in liver </li></ul><ul><li>25(OH)D 3 </li></ul><ul><li>1α-hydroxylase in kidney 24- hydroxylase </li></ul><ul><li>1,25-(OH) 2 D 3 24,25-(OH) 2 D 3 </li></ul><ul><li>active inactive </li></ul>PTH↑ Ca ↓ , P↓ ( - ) ( + ) Ca ↑ CT↑
  9. 9. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  10. 10. <ul><li>Etiology </li></ul><ul><li>* Inadequate gain of VitD from mother </li></ul><ul><li>* Inadequate direct exposure </li></ul><ul><li>to ultraviolet rays in sunlight (296-310 nm) </li></ul><ul><li>* Rapid growth low-birth weight infants </li></ul><ul><li>* Inadequate intake of VitD </li></ul><ul><li>The diets of infants may contain only small amounts of VitD </li></ul>
  11. 11. <ul><li>Predisposing factors to VitD deficiency </li></ul><ul><li>disorders interfere with absorption and </li></ul><ul><li>utilization of Vit D or Ca or P </li></ul><ul><li>celiac disease , steatorrhea, disorders of gastrointestine, biliary duct, pancrea, liver or kidney </li></ul><ul><li>drugs administration </li></ul><ul><li>* anticonvulsant therapy- (phenytoins, phenobarbital) </li></ul><ul><li>interfere with the metabolism of VitD </li></ul><ul><li>* Glucocorticoids--antagonistic to VitD in Ca transport </li></ul>
  12. 12. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  13. 13. <ul><li>normal osteogenesis : cartilagenous </li></ul><ul><li>intramembraneous </li></ul><ul><li>cartilage cells’ normal cycle--( Fig ) </li></ul><ul><li>zone of resting cartilage </li></ul><ul><li>zone of proliferating cartilage </li></ul><ul><li>zone of calcifying cartilage </li></ul><ul><li>zone of ossication: zone of preparatory </li></ul><ul><li>calcification(ZPC, 临时钙化带 ) </li></ul>Pathology
  14. 14. Fig.1 Levels of growth plate zone of resting cartilage zone of proliferating cartilage zone of calcifying cartilage zone of preparatory calcification
  15. 15. <ul><li>In Ricket cartilage cells fail to complete their normal </li></ul><ul><li>cycle of proliferation and degeneration; </li></ul><ul><li>subsequent failure of capillary penetration </li></ul><ul><li>occurs in a patchy manner(Fig) </li></ul>
  16. 16. <ul><li>enlarged costochondral </li></ul><ul><li>junction </li></ul>*Non-calcified, hypertrophied growth plate in rickets (R), compared to a normal growth plate (L).
  17. 17. Pathology <ul><li>Disturbance of sclerotic calcification </li></ul><ul><li>osteomalacia (骨质软化) </li></ul><ul><li>osteoid deposition( 骨样组织堆积 ) </li></ul>
  18. 18. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  19. 19. Pathogenesis <ul><li>can be conceptualized to be </li></ul><ul><li>the body’s attempt to maintain </li></ul><ul><li>normal serum calcium levels </li></ul>
  20. 20. <ul><li>VitD deficiency </li></ul><ul><li>↓ Ca, P absorption from the intestine </li></ul><ul><li>↓ serum Ca level </li></ul><ul><li>parathyroid gland </li></ul><ul><li>↓ P reabsorption ↑PTH PTH </li></ul><ul><li>in the kidney </li></ul><ul><li>↑ mobilization of </li></ul><ul><li>Ca ,P from the bone ↓serum Ca </li></ul><ul><li>↓ serum P serum Ca->,↓ </li></ul><ul><li>tetany </li></ul><ul><li>↓ Ca,P in ECF </li></ul><ul><li>failure in mineralization of osteoid tissue </li></ul><ul><li>and cartilaginous matrix </li></ul><ul><li>rickets Pathogenesis </li></ul>
  21. 21. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  22. 22. <ul><li>Clinical manifestations </li></ul><ul><li>Incidental age 3 m-2 yr </li></ul><ul><li>osseous changes in growing bone </li></ul><ul><li>relaxation of muscles and ligaments </li></ul><ul><li>nonspecific neuropsychatic symptoms </li></ul><ul><li>Severe case systemic </li></ul>
  23. 23. Clinical manifestations <ul><li>Stages </li></ul><ul><li>Early stage </li></ul><ul><li>Progressing stage </li></ul><ul><li>Convalescent stage (恢复期) </li></ul><ul><li>Sequelae stage (后遗症期) </li></ul>
  24. 24. Early stage (1) <ul><li>Symtoms <6(3)m </li></ul><ul><li>nonspecific neuropsychiatic--- </li></ul><ul><li>irritability </li></ul><ul><li>restless day and night(unstable sleeping) </li></ul><ul><li>increased sweating--particularly around </li></ul><ul><li>the head, no relation with weather </li></ul><ul><li>bare occiput( 枕秃 ) </li></ul><ul><li>Signs no obvious osseous change </li></ul>
  25. 25. bare occiput
  26. 26. Early stage (2) <ul><li>biochemical changes </li></ul><ul><li>serum Ca -> or ↓, P ↓, </li></ul><ul><li>ALP (Alkaline phosphatase) ↑(500μ/L) </li></ul><ul><li>25-(OH)D 3 ↓ , 1,25-(OH) 2 D 3 ↓ </li></ul><ul><li>Roentgenographic examination </li></ul><ul><li>Normal </li></ul><ul><li>or ZPC becomes unclear </li></ul>
  27. 27. Progressing stage <ul><li>* symptoms in early stage </li></ul><ul><li>* osseous changes </li></ul><ul><li>* retardation of development (movement) </li></ul>
  28. 28. Progressing stage osseous change <ul><li>* Head </li></ul><ul><li>craniotabes( 颅骨软化 )(3~6 m) </li></ul><ul><li>boxlike appearance ( Caput quadratum) (7~8m) </li></ul><ul><li>larger anterior fontanel , delayed closure(2y) </li></ul><ul><li>delayed eruption of the temporary teeth, </li></ul><ul><li>defects of the enamel and extensive caries, </li></ul><ul><li>calcifying permanent teeth’s being affected </li></ul>
  29. 29. boxlike appearance
  30. 30. Progressing stage osseous change <ul><li>* Chest (about 1yr) </li></ul><ul><li>beading of the ribs (rachitic rosary 佝偻病串珠 ) (Fig) </li></ul><ul><li>Harrison groove ( 赫氏沟 ) (Fig) </li></ul><ul><li>funnel-like chest ( 漏斗胸 ) (Fig) </li></ul><ul><li>pigeon breast deformity ( 鸡胸 ) (Fig) </li></ul>
  31. 31. rachitic rosary
  32. 32. Harrison groove Funnel-like chest L: pigeon breast
  33. 33. Progressing stage osseous change <ul><li>* Extremities </li></ul><ul><li>*thickening of the wrists and ankles(Fig ) </li></ul><ul><li>(Rachitic bracelets 佝偻病手镯、脚镯 ) </li></ul><ul><li>*bowlegs or knock-knees(Fig) </li></ul><ul><li>( O 型腿、 X 型腿) </li></ul>
  34. 34. R. thickening of the wrists L. thickening of the ankles
  35. 35. Thickening of the wrist Thickening of the ankles
  36. 36. R. bowlegs L. knock-knees
  37. 37. Progressing stage osseous change <ul><li>* others </li></ul><ul><li>spinal column (kyphosis 脊柱后突, s scoliosis 脊柱侧弯 ) </li></ul><ul><li>concomitant deformity of the pelvis, </li></ul><ul><li>ec flat pelvis </li></ul>
  38. 38. kyphosis & scoliosis
  39. 39. Progressing stage <ul><li>muscle and ligament </li></ul><ul><li>poorly developed and lack tone </li></ul><ul><li>(late in sitting, standing and walking) </li></ul><ul><li>overextension of the great joint </li></ul>
  40. 40. Clinical manifestations <ul><li>summarized as following table </li></ul><ul><li>Histological osteomalacia osteoid </li></ul><ul><li>Pathology (骨质软化) deposition </li></ul><ul><li>Head Craniotabes Caput </li></ul><ul><li>quadratum </li></ul><ul><li>chest Harrison groove, funnel Rachitic </li></ul><ul><li>-like chest ,Pigeon breast rosary </li></ul><ul><li>Spinal Kyphosis, Scoliosis </li></ul><ul><li>column </li></ul><ul><li>pelvis Flat pelvis </li></ul><ul><li>extremities Bowlegs, Knock-knees Rachitic </li></ul><ul><li>bracelets </li></ul>
  41. 41. Progressing stage <ul><li>Biochemical changes </li></ul><ul><li>serum Ca↓, P↓, </li></ul><ul><li>serum ALP (Alkaline phosphatase)↑↑ </li></ul><ul><li>serum 25-(OH)D↓ 1,25-(OH) 2 D 3 ↓ </li></ul><ul><li>urine cyclic AMP↑ </li></ul>
  42. 42. Progressing stage <ul><li>Roentgenographic examination (Fig) </li></ul><ul><li>* rachitic metaphysis </li></ul><ul><li>(deposition of nonrigid tissue) </li></ul><ul><li>* at the end of the shaft </li></ul><ul><li>(widdened, cupping, fraying) </li></ul><ul><li>** ZPC becomes unclear even disappear </li></ul><ul><li>* rarefied cortical bone (↓density ) </li></ul>
  43. 43. Upper limp Normal X rays Rachitic metaphysis
  44. 44. Lower limp Normal X rays Rachitic metaphysis
  45. 45. Convalescent stage <ul><li>(after adequate antirachitic treatment) </li></ul><ul><li>* Clinical manifestation improved--- </li></ul><ul><li>soon regain muscle tone, mentally improved </li></ul><ul><li>several days serum Ca, P ↑ ->N </li></ul><ul><li>4-6w ALP ↓-> N </li></ul><ul><li>* roentgenographicly improved---- </li></ul><ul><li>2-3w - ZPC reappears, bone density↑ </li></ul><ul><li>4w - ZPC, rachitic metaphysis and shafts </li></ul><ul><li>becomes united </li></ul>
  46. 46. Sequelae stage <ul><li>>2-3 yr </li></ul><ul><li>Severe rachitic child leave osseous deformities </li></ul><ul><li>— bowleg or knock-knee, </li></ul><ul><li>pigeon chest, funnel-like chest, </li></ul><ul><li>kyphosis, scoliosis, </li></ul><ul><li>head deformity, etc. </li></ul><ul><li>Biochemical change and Roentgenographic examination normal </li></ul>
  47. 47. Sequelae stage
  48. 48. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  49. 49. <ul><li>based on </li></ul><ul><li>a history of inadequate gain of VitD </li></ul><ul><li>Clinical observation </li></ul><ul><li>Confirmed by </li></ul><ul><li>biochemical test 25 - (OH)D↓(11~60 μ g/ml) </li></ul><ul><li>serum Ca↓, P↓, </li></ul><ul><li>serum AKP ↑↑ </li></ul><ul><li>roentgenograghic examination </li></ul>Diagnosis
  50. 50. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  51. 51. <ul><li>* Other rickets </li></ul><ul><li># familiar hypophosphatemia ( 家族性低磷血症) </li></ul><ul><li>or X-linked hypophosphatemia(XLH) </li></ul><ul><li># VitD-dependent rickets </li></ul><ul><li>or Ca ++ deficient form of rickets </li></ul><ul><li># Renal tubular acidosis </li></ul><ul><li>rickets, metabolic acidosis, polyuria, alkaluria </li></ul><ul><li># Renal Osteodystrophy </li></ul><ul><li># Hepatic diseases associated with rickets </li></ul>Differential diagnosis
  52. 52. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul>
  53. 53. <ul><li>* pregnant and lactating mothers </li></ul><ul><li>adequate sunlight; VitD 800U/d; </li></ul><ul><li>diet rich in Ca, P, VitD </li></ul><ul><li>* Infant </li></ul><ul><li>exposure to ultraviolet light </li></ul><ul><li>daily VitD supplementation </li></ul><ul><li>Term infant 400 U/d(2w~2yr) </li></ul><ul><li>premature infants 800 U/d(2w~3m), </li></ul><ul><li>400 U/d(3m~2yr) </li></ul><ul><li>*summer ! </li></ul>Prevention
  54. 54. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Physiological function and regulation of VitD </li></ul><ul><li>Etiology </li></ul><ul><li>Pathology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>&Tetany of VitD Deficiency </li></ul>
  55. 55. <ul><li>To control the progressive stage </li></ul><ul><li>prevent osseous deformity </li></ul><ul><li>N atural and artificial light </li></ul><ul><li>Nutrition </li></ul><ul><li>VitD analogue administration </li></ul><ul><li>Prevent and treat complication </li></ul>Treatment
  56. 56. <ul><li>VitD analogue administration </li></ul><ul><li>Orally VitD 2,000~4,000 IU/d × 2~4 W </li></ul><ul><li>1,25(OH) 2 D 3 0.5 ~ 2 μg/d × 2~4 W </li></ul><ul><li>then VitD 400 IU/d (10ug/d) </li></ul><ul><li>Single dose im VitD 3 200,000-300,000 IU </li></ul><ul><li>2-3m later VitD 400 IU/d </li></ul><ul><li>reevaluation q1m </li></ul>Treatment
  57. 57. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Chemical Pathology </li></ul><ul><li>Prediposing factor </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis & Differential diagnosis </li></ul><ul><li>Treatment </li></ul>
  58. 58. <ul><li>R achitic tetany </li></ul><ul><li>Incidental age <6m( 4m-3yr) </li></ul><ul><li>Form of plasma Ca </li></ul>8~10% 40% 45~50% IONIZED active form— PH 、 serum P BOUND protein COMPLEXED
  59. 59. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Chemical Pathology </li></ul><ul><li>Prediposing factor </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis & Differential diagnosis </li></ul><ul><li>Treatment </li></ul>
  60. 60. <ul><li>VitD deficiency </li></ul><ul><li>↓ Ca, P absorption from the intestine </li></ul><ul><li>↓ serum Ca level </li></ul><ul><li>parathyroid gland </li></ul><ul><li>↓ P reabsorption ↑PTH PTH </li></ul><ul><li>in the kidney </li></ul><ul><li>↑ mobilization of </li></ul><ul><li>Ca ,P from the bone ↓serum Ca </li></ul><ul><li>↓ serum P serum Ca->,↓ </li></ul><ul><li>tetany </li></ul><ul><li>↓ Ca,P in ECF </li></ul><ul><li>failure in mineralization of osteoid tissue </li></ul><ul><li>and cartilaginous matrix </li></ul><ul><li>rickets Pathogenesis </li></ul>
  61. 61. <ul><li>serum Ca 2+ <0.75~1mmol/L </li></ul><ul><li>serum Ca<1.75~1.88 mmol/L </li></ul><ul><li>the loss of the inhibitory control that </li></ul><ul><li>Ca exert on the neuromuscular junctions </li></ul><ul><li>muscular irritability </li></ul>Chemical Pathology
  62. 62. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Chemical Pathology </li></ul><ul><li>Prediposing factor </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis & Differential diagnosis </li></ul><ul><li>Treatment </li></ul>
  63. 63. Prediposing factor <ul><li>VitD deficiency </li></ul><ul><li>accompany with dull parathyroid response </li></ul><ul><li>Relative Ca deficiency </li></ul><ul><li>*enough exposure to sunlight (spring, summer) </li></ul><ul><li>or VitD administration </li></ul><ul><li>*concomitant inadequate Ca absortion </li></ul><ul><li>from the intestine </li></ul><ul><li>Pathological condition </li></ul><ul><li>fever, infection, neonatal asphyxia, high P level diet </li></ul>
  64. 64. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Chemical Pathology </li></ul><ul><li>Prediposing factor </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis & Differential diagnosis </li></ul><ul><li>Treatment </li></ul>
  65. 65. Clinical manifestations <ul><li>tetany and concurrent rickets </li></ul><ul><li>Manifest Tetany (serum Ca 2+ <0.75mmol/L </li></ul><ul><li>serum Ca<1.75 mmol/L) </li></ul><ul><li>latent tetany (serum Ca 2+ <0.75~1mmol/L </li></ul><ul><li>serum Ca<1.75~1.88 mmol/L) </li></ul>
  66. 66. <ul><li>Manifest Tetany </li></ul><ul><li>Convulsions brief but recurrent, </li></ul><ul><li>conscious between seizures </li></ul><ul><li>Laryngospasm inspiratory obstruction </li></ul><ul><li>high-pitched inspiratory crow apnea </li></ul><ul><li>Carpopedal spasm (Fig ) </li></ul>Clinical manifestations
  67. 67. Fig. Carpopedal spasm The wrist are flexed, the finger extended, the thumbs adducted over the palms, the feet extended and adducted.
  68. 68. <ul><li>latent tetany </li></ul><ul><li>symptoms are not evident, but can be elicited </li></ul><ul><li>by ischemia </li></ul><ul><li>or mechanical </li></ul><ul><li>or electrical </li></ul><ul><li>Chvostek sign, Peroneal sign, Trousseau sign </li></ul>Clinical manifestations stimulation of motor nerves
  69. 69. Latent tetany <ul><li>Chvostek sign facial spasm </li></ul><ul><li>tapping anterior to external auditory meatus </li></ul><ul><li>7th(facial) cranial nerve </li></ul><ul><li>Contraction of the orbicularis oris occurs with </li></ul><ul><li>a twitch of the upperlip or entire mouth </li></ul><ul><li>Peroneal sign pedal spasm </li></ul><ul><li>tapping the head of fibula </li></ul><ul><li>peroneal nerve </li></ul><ul><li>dorsiflexion and abduction of the foot </li></ul>
  70. 70. Latent tetany <ul><li>Trousseau sign carpospasm </li></ul><ul><li>A blood pressure cuff on the arm is inflated </li></ul><ul><li>above the systolic blood pressure for 5 min </li></ul><ul><li>Ischemia of motor nerves by reducing the blood supply </li></ul><ul><li>Carpopadal spasm </li></ul>
  71. 71. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Chemical Pathology </li></ul><ul><li>Prediposing factor </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis & Differential diagnosis </li></ul><ul><li>Treatment </li></ul>
  72. 72. <ul><li>bases on </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>manifest tetany, latent tetany </li></ul><ul><li>Biochemical changes </li></ul><ul><li>serum Ca 2+ <0.75~1mmol/L </li></ul><ul><li>serum Ca<1.75~1.88 mmol/L </li></ul><ul><li>The combined presence of rickets </li></ul>Dagnosis
  73. 73. <ul><li>Afebrile convulsion </li></ul><ul><li>H ypoglycemia (Glu ↓ ) </li></ul><ul><li>Hypom agnesemia (Mg ↓ ) </li></ul><ul><li>I nfantile spasms </li></ul><ul><li>Primary hypoparathyroidism(P ↑ ) </li></ul><ul><li>Infection of central nervous svstem </li></ul><ul><li>acute laryngitis </li></ul>Differential diagnosis
  74. 74. <ul><li>Prognosis </li></ul><ul><li>good unless treatment is delayed, </li></ul><ul><li>death rarely occurs </li></ul><ul><li>(may result from laryngospasm and cardiac dilation) </li></ul><ul><li>Prevention </li></ul><ul><li>identical to that of VitD deficient rickets </li></ul>
  75. 75. <ul><li>& Rickets of Vitamin D Deficiency </li></ul><ul><li>& Tetany of VitD Deficiency </li></ul><ul><li>Introduction </li></ul><ul><li>Chemical Pathology </li></ul><ul><li>Prediposing factor </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Diagnosis & Differential diagnosis </li></ul><ul><li>Treatment </li></ul>
  76. 76. <ul><li>Anticonvulsive treatment </li></ul><ul><li>* oxygen inhalation </li></ul><ul><li>* drugs </li></ul><ul><li>10% Chloral hydrate 0.4~0.5 ml/kg </li></ul><ul><li>r.e (retention enema) </li></ul><ul><li>Valium 0.1-0.3 mg/kg im. iv. </li></ul>Treatment
  77. 77. <ul><li>* Active treatment — </li></ul><ul><li>↑ serum Ca > tetany level </li></ul><ul><li>Calcium gluconate (10%) 5~10 ml in </li></ul><ul><li>GS(10%~25%) 10~20 ml </li></ul><ul><li>iv ( >10 min ) cardiac arrest ! </li></ul><ul><li>not im or s.c. Local necrosis! </li></ul><ul><li>* Treatment for rickets </li></ul>Treatment
  78. 78. Mbbs.weebly.com

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