Severe neonatal hypercalcemia related to maternal exposure to nutritional supplement containing Spirulina
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- Moulis, G., Batz, A., Durrieu, G. et al. Eur J Clin Pharmacol (2012) 68: 221. doi:10.1007/s00228-011-1113-5
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Spirulina platensis (Norst.) Geitler is a microalgae widely harvested in Asia, Africa and South America and used for centuries in these countries as a natural medicine and a nutritional complement. Indeed, this cyanobacterium could exert antioxidant, anti-inflammatory, anti-infective, hypolipidemic and anticancer properties [1–3]. It could also represent a nutritional supplement in developing countries, as it contains important quantities of proteins, minerals, B complex and liposoluble vitamins, particularly vitamin D . In developed countries, nutritional supplements containing S. platensis are increasingly used and sold over the counter. They represent a “natural”, “ethnic” and “obviously safe” medication. Pregnant women are particularly exposed to these supplements. We here report a case of severe neonatal hypercalcemia related to an excessive maternal exposure to S. platensis.
In April, 2010, a neonate was hospitalised the first day of his live in our university hospital for generalised seizures. His parents had no medical antecedent, there was no consanguinity, pregnancy was normal and the neonate was eutrophic with no malformation. Serum calcium was increased to 3.10 mmol/L (normal < 1.60 mmol/L), serum albumin was normal (37 g/L) and ionised calcium was increased to 1.49 mmol/L (normal < 1.20 mmol/L), as was serum phosphate (1.8 mmol/L, normal 0.8–1.3 mmol/L) and calciuria. Renal function and thyroid stimulating hormone levels were normal. Parathyroid hormone was low (6 pg/ml, normal 145–85 pg/ml), adjusted to hypercalcemia; 25-hydroxycholecalciferol was normal (254 ng/ml, normal > 10 ng/ml) and calcitriol (1,25-dihydroxycholecalciferol) was greatly increased (260 pg/ml, normal 18–60 pg/ml). In the mother’s serum, 25-hydroxycholecalciferol was normal (28 ng/ml) but calcitriol was increased (125 pg/ml, i.e. twice normal). Questioning revealed exposure to vitamin D supplementation at the beginning of pregnancy, and then daily exposure to S. platensis from the fourth month of pregnancy. S. platensis-related maternal intoxication with 25-hydroxycholecalciferol hydroxylated to calcitriol by the placental 1α-hydroxylase is suspected to be responsible for foetal hypercalcemia. Causality assessment was scored “likely” according to the World Health Organisation Uppsala Monitoring Centre (WHO-UMC) criteria .
The safety of nutritional supplements containing S. platensis is poorly evaluated. The supplements seem to contain low levels of algal toxins, particularly microcystins (hepatotoxins), but S. platensis decreases in vitro hepatocyte viability . Anatoxins (neurotoxins) have been detected in some S. platensis preparations . No human S. platensis-induced hepatitis or neurological disease has been reported to our knowledge. Sparse S. platensis-related adverse reactions have been reported and are linked to its immunomodulatory properties (hypersensitivity and autoimmune myositis) [7–9]. The adverse reaction described here is directly due to excessive ingestion of a nutritional supplement increasingly used worldwide. Patients should be aware of the risks of these products, which are renowned for being particularly safe. However, some preparations sold on the Internet also contain other cyanobacteria-producing toxins, which can be dangerous [10, 11].