Heterotopic ossification in a patient with paroxysmal sympathetic hyperactivity following multiple trauma complicated with vitamin D deficiency: a case report

BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) may occur in patients with traumatic brain injury. Heterotopic ossification (HO) has frequently been observed in patients with PSH and has been found to impair patients’ recoveries. However, the pathophysiology of HO in patients with PSH remains unelucidated. Vitamin D deficiency is a common abnormality among critically ill patients and may be associated not only with musculoskeletal complications, but also with high morbidity and mortality. The association between vitamin D deficiency and HO in patients with PSH has not yet been evaluated. CASE PRESENTATION: A 21-year-old man was in a motorcycle accident. The initial diagnosis was diffused axonal injury, thoracic aortic injury, bilateral lung contusion with hemopneumothorax, liver injury, vertebral injury of T5, along with fractures of the right humerus, left patella, bilateral scapula, and a stable pelvic fracture, with an Injury Severity Score of 50. Two weeks after admission, he was diagnosed with PSH. One month after the injury, decreased joint mobility and progressive pain were evident. Computed tomography (CT) showed HO in his humerus, ulna, radius, scapula, ilium, pubis, ischium, knee joint, patella, and tibia, as well as renal calculus. To evaluate metabolic bone abnormalities, we measured levels of 25-OH vitamin D, parathyroid hormone, calcitonin, procollagen type I N-terminal propeptide (a marker of bone formation), and tartrate-resistant acid phosphatase 5b (a marker of bone resorption). This revealed a vitamin D deficiency. Bisphosphonate agents and vitamin D were administered for 1 month. Thereafter, his symptoms, radiographic findings, and laboratory abnormalities improved, and he was transferred to another facility. CONCLUSIONS: HO in patients with PSH, following severe head injury, may be associated with vitamin D deficiency. Medication for vitamin-D-related metabolism abnormalities may represent a novel intervention for HO with PSH.