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Vitamin D deficiency rickets in resource-limited countries
María Inguanzo-Ortiz
Dr. José Molina Orosa Hospital, Paediatric department, Arrecife, Las Palmas, Spain

Article ID: 100003Z19MI2018
doi: 10.5348/100003Z19MI2018CL

Corresponding Author:
María Inguanzo-Ortiz

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Inguanzo-Ortiz M. Vitamin D deficiency rickets in resource-limited countries. J Case Rep Images Pediatr 2018;1:100003Z19MI2018.


A 13-year-old girl came to an Ethiopian clinic for the first time because of progressive limp and recurrent knee pain over several years. She came from a very poor family in a rural and remote area. She was dark-skinned and due to cultural beliefs, her clothes used to cover almost all of her skin. Her diet was strictly vegetarian resulting from lack of access to dairy or meat products. On physical examination, deformity in genu valgum (Figure 1) and severe widening of both knees (Figure 2) were both noteworthy and circumduction gait pattern was identified. She presented a Tanner stage 3. Based on anamnesis and clinical findings, rickets was suspected and patient was referred to a national hospital where diagnosis was biochemically confirmed. She received oral calcium and vitamin D supplements alongwith orthopedic treatment.

Keywords: Poverty, Physical examination, Rickets, Vitamin D deficiency

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Figure 1: Bilateral genu valgum in relation to vitamin D deficiency rickets.

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Figure 2: Severe widening of both knees in the same patient.


Rickets is the most common non-infectious disease in children in developing countries. The most frequent cause is vitamin D deficiency secondary to inadequate vitamin D intake or insufficient exposure to sunlight [1], [2].

Vitamin D deficiency causes hypocalcemia, which stimulates the activity of parathormone, causing bone resorption, thus altering the mineralization of growth cartilage and osteoid tissue, deforming them [3].

The diagnosis of rickets is suspected upon anamnesis, physical examination (long bone deformity, widening of the wrists, knees and chondrocostal junctions, growth retardation, craniotabes) and biochemical findings (deficits of 25-hydroxycalciferol and parathormone and elevated alkaline phosphatase with normal or decreased calcium) and is confirmed by radiology (growth plate widening and metaphyseal cupping and fraying). The treatment is vitamin D and adequate supplies of calcium and phosphorus [1], [2], [3], [4], [5].


Nutritional rickets is a worldwide public health problem and is completely preventable through the universal supplementation of infants under one year of age, pregnant women and individuals in all risk groups. In many developing countries, access to laboratory tests and radiology is unavailable; therefore, the diagnosis must be based on the clinical history and physical examination.

  1. Fischer PR, Thacher TD, Pettifor JM. Pediatric vitamin D and calcium nutrition in developing countries. Rev Endocr Metab Disord 2008 Sep;9(3):181–92.   [CrossRef]   [PubMed]    Back to citation no. 1
  2. Elder CJ, Bishop NJ. Rickets. Lancet 2014 May 10;383(9929):1665–76.   [CrossRef]   [PubMed]    Back to citation no. 2
  3. Munns CF, Shaw N, Kiely M, et al. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab 2016 Feb;101(2):394–415.   [CrossRef]   [PubMed]    Back to citation no. 3
  4. Allgrove J. Is nutritional rickets returning? Arch Dis Child. 2004 Aug;89(8):699–701.   [CrossRef]   [PubMed]    Back to citation no. 4
  5. Wagner C, Greer F. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 2008 Nov;122(5):1142–52.   [CrossRef]   [PubMed]    Back to citation no. 5

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Author Contributions
María Inguanzo-Ortiz – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of Submission
The corresponding author is the guarantor of submission.
Source of Support
Consent Statement
Written informed consent was obtained from the patient for publication of this clinical image.
Conflict of Interest
Author declares no conflict of interest.
© 2018 María Inguanzo-Ortiz et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.