Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 5  |  Issue : 4  |  Page : 256-257  

Oyster shell calcium induced parotid swelling


Adverse Drug Reaction Monitoring Centre, Department of Clinical Pharmacology, JIPMER, Gorimedu, Puducherry, India

Date of Submission28-Oct-2013
Date of Decision09-Jan-2014
Date of Acceptance16-Feb-2014
Date of Web Publication9-Oct-2014

Correspondence Address:
Muthiah Palaniappan
Department of Clinical Pharmacology, Adverse Drug Reaction Monitoring Centre, JIPMER, Gorimedu, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-500X.142446

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   Abstract 

A 59 year old female consumer was started on therapy with oyster shell calcium in combination with vitamin D3 and she presented with swelling below the ear, after two doses. She stopped the drug by herself and the swelling disappeared in one day. She started the drug one day after recovery and again she developed the swelling. She was advised to stop the drug with a suggestion to take lemon to enhance parotid secretion and the swelling subsided. Calcium plays major role in salivary secretion and studies have shown reduced parotid secretion in rats, deficient of vitamin D. But in humans involvement of calcium and vitamin D3 in parotid secretion is unknown. However, the patient had no history of reaction though she had previously taken vitamin D3 with calcium carbonate which was not from oyster shell. Hence, we ruled out vitamin D3 in this reaction and suspecting oyster shell calcium as a culprit. This adverse drug reaction (ADR) was assessed using World Health Organization (WHO) causality assessment, Naranjo's and Hartwig severity scales. As per WHO causality assessment scale, the ADR was classified as "certain". This reaction was analyzed as per Naranjo's algorithm and was classified as probable. According to Hartwig's severity scale the reaction was rated as mild. Our case is an example of a mild but rare adverse effect of oyster shell calcium carbonate which is widely used.

Keywords: Adverse drug reaction, oyster shell calcium, parotid swelling


How to cite this article:
Palaniappan M, Selvarajan S, Srinivasamurthy S, Chandrasekaran A. Oyster shell calcium induced parotid swelling . J Pharmacol Pharmacother 2014;5:256-7

How to cite this URL:
Palaniappan M, Selvarajan S, Srinivasamurthy S, Chandrasekaran A. Oyster shell calcium induced parotid swelling . J Pharmacol Pharmacother [serial online] 2014 [cited 2019 Jul 18];5:256-7. Available from: http://www.jpharmacol.com/text.asp?2014/5/4/256/142446


   Introduction Top


A patient was prescribed oyster shell calcium (500 mg/day) with vitamin D3 (250 IU/day) as supplement and developed parotid enlargement after two doses. Parotid gland may enlarge due to obstruction in parotid duct, inflammation, alcohol intake, diabetes mellitus, cancer, mumps and rheumatoid arthritis. Calcium plays a major role in salivary secretion and studies have shown reduced parotid secretion in vitamin D deficient rats, but in humans the involvement of calcium and vitamin D in parotid secretion is unknown. [1] Combination of calcium and vitamin D3 is used as supplements in elderly, pregnant, lactating and postmenopausal women. Oyster shell is one of the commonly used sources of calcium. Indian Council of Medical Research recommends 600 mg calcium and 400 IU of vitamin D3 per day. [2] In view of the widespread use of this combination, we would like to report that calcium obtained from oyster shell and vitamin D3 may result in parotid swelling in susceptible individuals.


   Case report Top


This was a case report of a 59-year-old patient who presented with right parotid enlargement after two doses of oyster shell calcium 500 mg and vitamin D3 250 IU in fixed dose combination. Following parotid enlargement, the patient stopped the drug herself which was followed by regression of the swelling within a day. Later, she restarted the drug which resulted in reappearance of enlargement of same parotid gland. She consulted a physician and was advised to stop the drug with assurance of no need for treatment. Subsequently she was also referred to adverse drug reaction (ADR) monitoring center, where ADR was documented and analyzed. She recovered completely in 2 days. There was no history of any other concomitant drugs and she had no history of diabetes, rheumatoid arthritis, malignancy and thyroid disorder. She did not have history of insect bite, exposure to allergens or infections. Earlier she had history of intake of calcium not obtained from oyster shell with no reaction.

ADR was assessed using World Health Organization (WHO) causality assessment and Naranjo's scales. As per WHO causality assessment scale, the ADR was classified as "certain" since it showed temporal association with positive de-challenge and re-challenge tests. [3] This reaction was analyzed as per Naranjo's algorithm with a score of 7 and was classified as probable. [4] According to Hartwig's severity scale the reaction was rated as mild. [5]


   Discussion Top


Calcium is essential for secretion of water and electrolyte from parotid, further; it is shown to be vitamin D dependent. [6] Common adverse effects reported with overdose of calcium are confusion, constipation, abdominal pain, muscle twitching. [7] Recently, there is concern of myocardial infarction risk with use of calcium supplements with or without vitamin D. [8],[9] Nevertheless, it is suggested to supplement calcium in more frequent and lower doses to prevent age related secondary hyperparathyroidism and osteoporotic fractures. [10]

There is a report of bilateral submandibular salivary stones formation in a child which was attributed to high dietary intake of calcium. [11] However, in our case hypercalcemia would be least likely. Further, there was no evidence of stone formation but the parotid enlargement occurred within 2 days of starting the drug.

Drug induced parotid enlargement is less common and is reported with drugs such as clonazepam, clozapine, butazones, bretylium, asparaginase, methyldopa, iodide preparations and terbinafine. [12],[13] Further, hypersensitivity reactions associated with xerostomia following oysters intake, mercury and lead poisoning would also lead to parotid swelling. [14] Ross et al. has demonstrated that naturally derived calcium supplements including oyster shell contains significant amount of lead. [15] Thus, it could be hypothesized that hypersensitivity due to oyster or lead content of these supplements might have contributed for parotid swelling.

Vitamin D receptors have been demonstrated in rat parotid gland, but the role of vitamin D3 on parotid secretion is unknown. [16] However, the patient had no history of reaction though she had previously taken vitamin D3 with calcium carbonate which was not from oyster shell. Hence, we ruled out vitamin D3 in this reaction and suspected oyster shell calcium as the culprit.

Given that calcium is widely used as supplementation in elderly women as part of prevention of osteoporosis, this reaction is of significance. Our case is an example of a mild but rare adverse effect of oyster shell calcium carbonate which is widely used.

 
   References Top

1.
Glijer B, Peterfy C, Tenenhouse A. The effect of vitamin D deficiency on secretion of saliva by rat parotid gland in vivo. J Physiol 1985;363:323-34.  Back to cited text no. 1
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2.
Nutrient requirements and recommended dietary allowances for Indians. A Report of the Expert Group of the Indian Council of Medical Research, 2009. Available from: http://www.icmr.nic.in/final/RDA-2010.pdf. [Last cited on 2013 Aug 28].  Back to cited text no. 2
    
3.
The use of the WHO-UMC system for standardised case causality assessment. Available from: http://www.who-umc.org/Graphics/24734.pdf. [Last cited on 2013 Dec 02].  Back to cited text no. 3
    
4.
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45.  Back to cited text no. 4
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5.
Hartwig SC, Siegel J, Schneider PJ. Preventability and severity assessment in reporting adverse drug reactions. Am J Hosp Pharm 1992;49:2229-32.  Back to cited text no. 5
    
6.
Goodwin D, Noff D, Edelstein S. The parotid gland: A new target organ for vitamin D action. Biochim Biophys Acta 1978;539:249-52.  Back to cited text no. 6
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7.
Calcium carbonate overdose. Available from: http://www.nlm.nih.gov, http://www.nlm.nih.gov/medlineplus/ency/article/002605.htm. [Last cited on 2013 Dec 02].  Back to cited text no. 7
    
8.
Bolland MJ, Grey A, Avenell A, Gamble GD, Reid IR. Calcium supplements with or without vitamin D and risk of cardiovascular events: Reanalysis of the Women's Health Initiative limited access dataset and meta-analysis. BMJ 2011;342:d2040.  Back to cited text no. 8
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9.
Li K, Kaaks R, Linseisen J, Rohrmann S. Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012;98:920-5.  Back to cited text no. 9
    
10.
Verbrugge FH, Gielen E, Milisen K, Boonen S. Who should receive calcium and vitamin D supplementation? Age Ageing 2012;41:576-80.  Back to cited text no. 10
    
11.
Waseem Z, Forte V. An unusual case of bilateral submandibular sialolithiasis in a young female patient. Int J Pediatr Otorhinolaryngol 2005;69:691-4.  Back to cited text no. 11
    
12.
Martin SD. Drug-induced parotid swelling. Br J Hosp Med 1993;50:426.  Back to cited text no. 12
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13.
Torrens JK, McWhinney PH. Parotid swelling and terbinafine. BMJ 1998;316:440-1.  Back to cited text no. 13
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14.
Watt J. Benign parotid swellings: A review. Proc R Soc Med 1977;70:483-6.  Back to cited text no. 14
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15.
Ross EA, Szabo NJ, Tebbett IR. Lead content of calcium supplements. JAMA 2000;284:1425-9.  Back to cited text no. 15
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16.
Peterfy C, Tenenhouse A. Vitamin D receptors in isolated rat parotid gland acinar cells. Biochim Biophys Acta 1982;721:158-63.  Back to cited text no. 16
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