Download 1.3 Hypervitaminosis A from fish oil

Hypervitaminosis A following long-term use
of high-dose fish oil supplements.
Blair P. Grubb. Chest. May 1990 v97 n5 p1260(1).
Full Text:COPYRIGHT 1990 American College of Chest Physicians
The use of various dietary supplements containing fish oils has become popular as a method of
reducing the risk of developing cardiovascular disease. However, consumption of large amounts of
these substances may pose some potential hazards. Described herein is a patient who developed
hypervitaminosis A after prolonged fish oil supplement ingestion.
The use of fish oil supplements recently has become quite popular as a potential method of lowering
plasma lipids, inhibiting platelet aggregation, decreasing blood pressure and increasing plasma HDL
levels.[1] However, the consumption of large dosages of these substances may not be without risk, as
they may contain relatively high levels of both vitamins A and D.[2] Reported here is a case of
hypervitaminosis A secondary to chronic fish oil capsule ingestion alone.
CASE REPORT
A 35-year-old white man presented complaining of anorexia, nausea, fatigue and mild frontal
headache. He had been well until approximately one year prior to presentation when he began to
consume between 30 and 50 capsules a day of various commercial fish oil preparations. These
principally included Max EPA (R.P. Scherer Company, Clearwater, FL), Pro Mega (Parke-Davis Co,
Morris Plains, NJ), EPA-Chol (People's Drugs, Alexandria, VA), Twin EPA (Twin Labs, Rokenkona, NY)
and Super EPA (Pharmacaps, Inc, Elizabeth, NJ). He reported taking no other medications or vitamin
supplements during this time, nor did he report high dietary sources of vitamin A. However, it was
later found that the patient had also consumed an undetermined number of cod liver oil capsules
during that year. Approximately one month prior to presentation he began to notice chronic fatigue
and malaise as well as dry and itchy skin. One week prior to admission he began to complain of
myalgia, anorexia and nausea and two days prior he began to have episodes of vomiting. Vital signs
showed a blood pressure of 120/80 mm Hg, a respiration rate of 16 breaths per minute, a pulse rate
of 80 beats per minute and a temperature of 38.3 [degrees] C orally. On physical examination, he was
noted to have diffusely dry skin with fissures around the mouth. Ophthalmologic examination showed
no papilledema. Pulmonary, cardiac and neurologic examinations were unremarkable. Abdominal
examination revealed mild hepatomegaly but was otherwise unremarkable. A scan of the liver and
spleen showed hepatomegaly with a liver size of 14 cm. The electrolyte, BUN, creatinine, calcium and
alkaline phosphatase levels were normal as were the complete blood cell count and urinalysis findings.
The SGOT was elevated to 102 IU/L (normal, 10 to 40 IU/L) and the SGPT was 80 IU/L (normal, <40
IU/L)/ The fasting blood lipid profile showed a total cholesterol value of 215 mg/dl, an HDI cholesterol
level of 38 mg/dl, a LDL cholesterol value of 150 mg/dl and a triglyceride level of 170 mg/dl. A serum
vitamin A level was 482 [mu]g/dl (normal, 30 to 70 [mu]g/dl). The patient's fish oil supplements were
discontinued and his symptoms gradually disappeared by the end of one week. Follow-up at one
month showed resolution of his dry skin and hepatomegaly and the vitamin A level was 68 [mu]g/dl.
The fasting blood lipid profile at that time showed a total cholesterol level of 212 mg/dl, an HDL
cholesterol value of 38 mg/dl, an LDL cholesterol level of 138 mg/
COMMENTS
Hypervitaminosis A is a well described clinical entity which has usually been observed following the
chronic ingestion of vitamin A supplements.[3,4] It has been reported that as little as 10,000 units of
vitamin A intake daily may be sufficient to cause symptoms of hypervitaminosis.[4] Patients usually
present complaining of fatigue, irritability, dry itchy skin, loss of body hair, headache, myalgia, lowgrade fever, anorexia and vomiting.[3] Hepatomegaly often is present on physical examination,
presumably due to an accumulation of vitamin A in the liver. Vitamin A toxicity results when the
transport system for vitamin A from the liver to the peripheral tissues is overtaxed and free retinal
and/or retinoic acid interact with cell and organelle membranes.[5] Concentrations of vitamin A in
plasma over 300 [mu]g/dl are considered diagnostic of the condition.[6]
Fish oils in various forms recently have been the subject of considerable media attention, principally
due to their reported ability to prevent the development of coronary artery disease. It is interesting to
note, however, that the patient's massive intake of fish oils did not significantly alter his blood lipid
picture, and actually caused an increase in his LDL level. Similar findings during periods of fish oil
intake were reported by Harris et al.[7] Some of the available commercial fish oil preparations
(especially those containing large amounts of cod liver oil), may contain significant amounts of vitamin
A.[1,2] When used at the recommended dosages (usually six capsules a day), these agents are
relatively safe. However, the quantity of fish oil capsules taken by this patient far exceeded the dose
usually taken or recommended. The case reported here suggests that an increase in episodes of
hypervitaminosis A may occur owing to the overzealous use of fish oil supplements by individuals
wishing to lower their risk of developing coronary artery disease.
REFERENCES
[1] Yetiv JZ. Clinical applications of fish oils. JAMA 1988; 260:665-70
[2] Baird MB, Hough JL. More on fish oil. N Engl J Med 1987; 316:626
[3] Stimson WH. Vitamin A intoxication in adults. N Engl J Med 1961; 265:369-373
[4] Farris WA, Erdman JW. Protracted hypervitaminosis A following long-term low-level intake. JAMA
1982; 247:1317-18
[5] Smith F, Goodman D. Vitamin A transport in human vitamin A toxicity. N Engl J Med 1976;
294:805-08
[6] Mandel G, Cohn V. Hypervitaminosis A. In: Goodman A, Goodman L, Gilman A, eds. The
pharmacologic basis of therapeutics. New York: Macmillan Publishing Co, 1980:1587
[7] Harris W, Dujovne C, Zucker M, Johnson B. Effects of a low saturated fat, low cholesterol fish oil
supplement in hypertrigly-ceridemic patients. Ann Intern Med 1980; 109:465-70
Record Number: A13475144