rickets

rickets, disease of infancy and childhood characterized by softening of the bones, leading to abnormal bone growth and caused by a lack of vitamin D in the body. When the disorder occurs in adults, it is known as osteomalacia.

The relationship between vitamin D and bone rigidity

Vitamin D (or, more specifically, calcitriol) is a steroid hormone that is produced in the skin by the action of sunlight’s ultraviolet rays on its precursor, 7-dehydrocholesterol (provitamin D₃). Vitamin D is also absorbed from the diet, especially from fortified milk and from liver and fish oils.

Following its production in the skin or absorption in the gastrointestinal tract, vitamin D is transported through the blood to the liver, where it is converted to calcidiol (25-hydroxyvitamin D). Calcidiol is then transported through the blood to the kidneys, where it is metabolized to calcitriol (1,25-dihydroxyvitamin D), the most active form of vitamin D. Calcitriol stimulates the small intestine, bone, and kidney to absorb calcium, as well as the minerals phosphate and magnesium; in bone, the absorption process leads to the deposition of the inorganic salt calcium phosphate, which is responsible for bone rigidity.

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In the absence of calcitriol, the calcium absorption process does not proceed normally. Low serum calcium concentrations prompt the secretion of a substance known as parathormone from the parathyroid glands; parathormone liberates calcium from bone in order to restore serum calcium concentrations. Hence, although the production of osteoid, the protein matrix on which calcium is deposited, is normal or increased in vitamin D deficiency, the matrix is poorly calcified. This results in soft bones, the literal meaning of the term osteomalacia.

Causes of rickets

While rickets is said to arise generally from a lack of vitamin D in the body, specific causes have been described. For example, vitamin D deficiency can result from a lack of the vitamin in the diet, insufficient conversion in the skin by ultraviolet light, inefficient dietary absorption, or the abnormal conversion of vitamin D to its metabolites. Contributing factors to the development of rickets in children include having been breast-fed exclusively for a prolonged period of time (human breast milk contains low amounts of vitamin D), living in temperate regions where sunlight exposure is limited in winter, and having dark-pigmented skin. Certain underlying conditions, such as liver, kidney, or gastrointestinal disease, can interfere with the normal metabolism or absorption of vitamin D. In chronic kidney disease, for example, the conversion of calcidiol to calcitriol is decreased or absent, resulting in an inability to absorb calcium.

In other instances, rickets and rickets-type disorders may be caused by inherited defects in genes whose products are involved in vitamin D or phosphate metabolism. In hereditary hypophosphatemic rickets, for example, an increased rate of phosphate clearance from the body by the renal tubules of the kidneys results in loss of bone mineral and, in severe cases, in rickets-type deformities and dwarfism. The disease, which is rare and is most commonly inherited as an X-linked dominant disorder (one copy of the mutated gene on the X chromosome is sufficient to produce the disease), tends to start in early childhood.

Another inherited form of rickets is vitamin D-dependent rickets type I (VDDRI), in which a defect in the enzyme that converts calcidiol to calcitriol produces vitamin D deficiency and causes the loss of calcium from bone. Vitamin D-dependent rickets type II (VDDRII) involves loss-of-function mutations in a gene for the vitamin D receptor, with the result that tissues are unable to absorb calcitriol. VDDRII is associated with rickets, hypocalcemia (decreased serum calcium), and in some cases alopecia (baldness). Both VDDRI and VDDRII are autosomal recessive (two copies of the mutated gene, one from each parent, are required to cause disease) and manifest in infancy or early childhood.

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A variety of similar syndromes exist. For example, de Toni–Fanconi syndrome is characterized by rickets deformities and renal tubule defects. In addition, tumours that produce substances capable of inhibiting the reabsorption of phosphate by the kidneys (oncogenic osteomalacia) may lead to rickets-type deformities. Tumours that cause hypophosphatemia (decreased serum phosphate) are often hard to locate because they are small and occur in fibrous or mesenchymal tissue, including bone.

Symptoms of rickets

Softened bones are readily curved, and their growth is stunted. In rickets there also is an overgrowth of cartilage, resulting in the enlargement of the ends of long bones and in the junction of the ribs with the rib cage in the chest (rachitic rosary). Common early symptoms of rickets include restlessness, profuse sweating, lack of muscle tone in the limbs and abdomen, softening of the bones of the skull, delay in learning to sit, crawl, and walk, and delay in the eruption of the teeth. Tetany (spasms of the hands and feet as well as cramps and twitching of the muscles) may also occur. Unless treatment is begun early, rickets may produce conditions such as bowlegs, knock-knees, a bulging forehead, and short stature. A narrowed chest and pelvis may be responsible later in life for increased susceptibility to lung diseases and difficulties in childbearing, respectively.

Diagnosis and treatment of rickets

Rickets is diagnosed through an assessment of family medical history, X-rays, and blood and urine tests. A combination of X-rays, which reveal bone deformities characteristic of rickets, and knowledge of calcium, phosphate, calcidiol, and calcitriol levels typically leads to a definitive diagnosis.

Rickets is usually effectively treated with large supplemental doses of vitamin D concentrates (often in the form of calcitriol), with exposure to sunlight, and with a well-balanced diet. Vitamin D supplementation, usually in fortified milk, has been important in preventing the incidence of rickets in northern and temperate climates. Inherited forms of rickets often are treated with massive doses of vitamin D and supplementary phosphate and calcium.

The first treatment found to be effective for rickets was cod liver oil. Cod liver oil and exposure to sunlight were recognized as preventive and curative therapies for nutritional rickets in humans in the 18th and 19th centuries, respectively; however, these treatments were not generally accepted until the early 20th century. The existence of a vitamin able to mimic the effects of cod liver oil was indicated in experimental animals in 1918. In 1924 it was demonstrated that the curative effects of ultraviolet light resulted from the formation of vitamin D by such irradiation. Up until that time, vitamin D deficiency was a worldwide problem, particularly in the temperate zones. With the isolation of vitamin D₂ (ergocalciferol, the form of vitamin D found in plants and fungi) in 1930–31 in England and Germany and of 7-dehydrocholesterol (the precursor of vitamin D) from hog skin in 1937 in Germany, the fortification of foods with the vitamin became possible.

Epidemiology of rickets

As a result of therapeutic developments in the 20th century, the prevalence of rickets decreased, particularly in developed countries such as the United States, the United Kingdom, and Australia, where it eventually became rare. Today the distribution and prevalence of rickets are aligned primarily with risk factors. Hence, it is most prevalent in peoples who are dark-skinned and in developing countries where access to vitamin D-fortified foods is lacking. Africa, the Middle East, and parts of Asia rank among the world’s most heavily affected regions.