Bulging anterior fontanelle: an unusual presenting sign of nutritional rickets

Abstract

Aim: To report the first case series of infants with nutritional rickets who presented with bulging anterior fontanelle
Methods: infants who were admitted to Alrass General Hospital, Qassim, Saudi Arabia, between October 2004 and October 2007, with bulging anterior fontanelle and later found to have nutritional rickets were reviewed. Diagnosis of rickets was based on typical biochemical and radiological findings with or without clinical signs of rickets and with a good response to treatment with vitamin D with or without calcium.
Results: Nine cases of nutritional rickets who presented with bulging anterior fontanelle are reported. All were below 12 months of age and the majorities are boys. All patients are exclusively breast-fed. Five cases had hypocalcaemia and three of them presented with hypocalcaemic seizures.
Five cases showed no clinical signs of rickets. Clinical, biochemical and radiological signs of rickets as well as the status of the anterior fontanelle reverted to normal within six weeks after treatment with vitamin D in all except one patient who took four months to respond.
Conclusion: Nutritional rickets remains a problem in Saudi Arabia. A bulging anterior fontanelle is an important, but under- recognized presenting feature of nutritional rickets. Recognition of this association will alley anxiety when confronted with a case of rickets with a bulging anterior
fontanelle.

Keywords: hypocalcaemic seizures, vitamin D, hypophosphataesia.