Psychosis associated with Vitamin B12 deficiency ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O) Psychosis associated with Vitamin B12deficiency - A case report with review of literature Nayana Naik1*, Mary C. Dsouza11Assistant Professor, Institute of Psychiatry and Human Behavior (IPHB), Bambolim, Goa, India *Corresponding author email: [email protected] to cite this article: Nayana Naik, Mary C. Dsouza. Psychosis associated with Vitamin B12deficiency - A case report with review of literature. IAIM, 2015; 2(2): 138-142. Available online at www.iaimjournal.comReceived on: 11-01-2015 Accepted on: 19-01-2015AbstractVitamin B12 is one of the essential vitamins affecting various systems of the body. Cases ofneuropsychiatric disorders due to its deficiency are more common in elderly patients with aprevalence rate of 10-20%; however there have been few cases reported in children and adolescentsas well. The most common psychiatric symptoms reported in the literature associated with vitaminB12 deficiency was depression, mania, psychotic symptoms, cognitive impairment, dementia,delirium, acute confusional states and obsessive compulsive disorder. Subacute combineddegeneration (SCD) is a neurological complication of vitamin B12 deficiency, characterized bydemyelination of the dorsal and lateral spinal cord. With an early diagnosis and treatment, furtherdevelopment of symptoms can be prevented, before psychosis; dementia and severe depression candevelop. The treatment is simple and effective and often gives very good results in these symptoms.Here we have reported a case of vitamin B12 deficiency in 19 years old, male who presented with6 months history of paraparesis and 3 months history of psychosis. The patient was nonvegetarian. Past medical history, psychiatric and family history was insignificant. Premorbidpersonality was unremarkable with no substance use/ exposure or infections. No stressors werepresent. He was diagnosed with sub acute combined degeneration with psychosis due to vitaminB12 deficiency. He was treated with antipsychotics and parenteral vitamin B12. Patient improvedbut some residual weakness persisted in lower limbs after 10 days of parental treatment withVitamin B12.Key wordsVitamin B12 deficiency, Psychosis, Subacute combined degeneration. Page 138International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015.Copy right © 2015, IAIM, All Rights Reserved.
Psychosis associated with Vitamin B12 deficiency ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Introduction psychopathology and chronic medical disorders. Patient was seen by Psychiatrist in hospitalVitamin B12, also known as Cobalamin is an setting and he was treated with antipsychotics,essential nutrient. Its deficiency is a common Olanzapine 15 mg/day and trifluperazine 15finding in developing countries, around the mg/day and was given a course ofworld and strikes all ages and sexes. Macrocytic electroconvulsive therapy (ECTs). He improvedanemia, neuropsychiatric symptoms and in his psychiatric condition but his neurologicalglossitis are the typical symptoms reported, but condition started deteriorating hence wasthis triad is lacking in many cases. The serum referred to neurology and later to psychiatry.vitamin B12 is the best first line test; however, On physical examination, power in both uppernormal level does not exclude deficiency, limbs was grade 5 and lower limb was grade 4.therefore when the level of vitamin B12 is in the Right toe dorsiflexion was weak and bilateral toelow normal range, high serum levels of grips were weak. His deep tendon reflexes weremethylmalonic acid and homocysteine should be depressed at both ankles. Joint position senseused for diagnosis. There are various causes of and vibration was impaired bilaterally up toB12 deficiency reported in the literature but ankle joint. Right Babinski reflex was present. Hismost common cause is pernicious anemia. Other cranial nerves were intact. His gait wascauses include strict vegetarians, atrophic abnormal as there was dragging of right foot. Ongastritis, stomach ulcers, surgically removed mental status examination, he was conscious,stomach or intestine, crohn’s disease, celiac co-operative, relevant, and coherent. He denieddisease, bacterial growth particularly any psychotic experiences and depressivehelicobacter pylori, or parasite and medications cognition. He was oriented, his memory wasincluding proton pump inhibitors (PPIs) for intact. His mini mental status examinationindigestion. We have reported a case of 19 years (MMSE) score was 30/30. His hemoglobin (Hb)old boy with vitamin B12 deficiency with 14.3 gm/dl, total white blood cell (WBC) 7600neuropsychiatric symptoms. cu/mm, differential counts, platelets, renalCase report function tests, fasting blood sugar, lipid profile, liver function tests were within normal range.Patient was apparently well prior to 6 months, Thyroid function test was normal. Serumwhen he started with difficulty in walking as his calcium, phosphorous and uric acid level wereright foot started getting inverted. This was also within normal range. HIV - Elisa test wasfollowed by abnormal behavior for 3 month, negative. His Serum Vitamin B12 level was 143consisted of running out of the house, talking pg/ml (211-911 pg/ml is normal range).irrelevantly, persecutory ideas against the family His cerebrospinal fluid (CSF) was also normal.and neighbors, severe agitation, decreased Fundus examination did not reveal anyeating and disturbed sleep. No history of abnormality. No Kayser-Fleischer ring (K.F.)psychoactive substance use, encephalitis, use of noted on slit lamp examination of eye. Plain CTantipsychotics/ antiemetic, exposure to carbon- of brain was normal. MRI scan of the wholemonoxide or organophosphate compounds or spine was performed using sagittal T2W andstressors was present. The patient was non STIR sequences revealed no significantvegetarian. Past medical history and family abnormality.history was unremarkable for bothInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 139Copy right © 2015, IAIM, All Rights Reserved.
Psychosis associated with Vitamin B12 deficiency ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Based on the clinical history, neuropsychiatric Murat Dogan, et al. (2009) reported a case of 12examination and low levels of vitamin B12, a years old boy developing psychosis and extradiagnosis of Subacute combined degeneration pyramidal symptoms due to B12 and folate(SCD) with psychosis with vitamin B12 deficiency deficiency, improved with injectable B12 dailywas made and he was started on injectable and folic acid twice a week. His B12 level was <vitamin B12 supplements (1000 mcg) for 10 days 111 pmol/L, folate 5.8 nmol/L, Hb 8.4 mmol/L,and later on shifted to oral preparation of MCV 98 [2]. Ali Evren (2012) reported 16 yearsvitamin B12. His neurological deficit improved old boy with memory problems, irritability,partially within 10 days and then he was sleeplessness, apathy, hallucinations, delusions,discharged from hospital with oral maintenance concentration problems, crying, ataxia, shouldertherapy of vitamin B12 and low doses of and elbow rigidity, coordination problems,antipsychotics, Olanzapine 10 mg/day and diminished thinking capability, glossitis withtrifluperazine 10 mg/day with further plan to Vitamin B12 level 122 pmol/L, Hb 6.2 mmol/L,reduce and stop antipsychotics at follow up. and MCV 98. He was treated with low doseHowever patient failed to follow up. Risperidone 0.5 mg/day + B12 injections 500 mcg a day. Risperidone was stopped in theDiscussion second week; B12 injections were maintained monthly. Symptoms did not come back in theThis patient visited a Psychiatrist in a private following six months [3]. These reported casessetting due to florid psychotic symptoms which presented with various neuropsychiatricovershadowed neurological symptoms like symptoms associated with low levels of vitaminparaparesis and numbness of the lower limbs; B12 and hemoglobin.hence neurological symptoms were probably Vitamin B12 deficiency usually presents withoverlooked during the course of treatment. He pernicious anemia and various neuropsychiatricwas treated for psychosis with antipsychotics manifestations, whereas in our patientand electroconvulsive treatment (ECT). He hemoglobin level was normal (14.3 gm/dl).showed partial improvement in psychotic Numerous cases reported in the literature statefeatures; however his neurological condition that neuropsychiatric symptoms can antedatestarted to deteriorate hence he reported to a anemia for years together. Greenfield andneurologist in a tertiary care hospital. O’Flynn (1933) stated that 14% of patients withVitamin B12 deficiency typically appears as combined degeneration of the spinal cord havelower-extremity paresthesia or ataxia, most normal blood values [4]. In 1960, The Britishoften with concurrent folate deficiency and Medical Journal published A.D.M Smith’smegaloblastic anemia [1]. Psychiatric symptoms ‘Megaloblastic Madness’. He wrote: “Thedue to a B12 deficiency commonly occur in the occurrence of subacute combined degenerationelderly, however these symptoms are rare in of the cord prior to the onset of anemia is wellchildren and adolescents; hence they tend to be recognized and clinicians are now fully alive tooverlooked, like in our patient where organic this possibility.” “The time-lag may benature of the Psychosis was probably not considerable and may give rise to diagnosticentertained due to young age. difficulty unless this situation is constantly borne in mind. Owing to the many tragedies that have resulted from unawareness, with subsequentInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 140Copy right © 2015, IAIM, All Rights Reserved.
Psychosis associated with Vitamin B12 deficiency ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)irreversible cord damage, it is now unusual to suggestive of Psychosis in the family. We feelcome across cases of this nature” [5]. that had his psychosis been recognized and treated as a symptom of vitamin B12 deficiencyEstimation of thyroid function test is also very much earlier, a complete reversal of hisimportant in B12 deficiency as there is high neuropsychiatric symptoms might have beenprevalence of B12 deficiency in patient with expected. Although patient showedhypothyroidism. Jabbar A, et al. (2008) improvement in his psychosis withevaluated 116 hypothyroid patients from his antipsychotics and ECTs, his neurologicalendocrine clinic for signs and symptoms of symptoms improved with injectable vitaminvitamin B12 deficiency and found that there is B12.high (approximately 40%) prevalence of B12deficiency in hypothyroid patients [6]. Our Conclusionpatient did not show signs of hypothyroidism.There are rare cases reported with association Psychiatric symptoms of a B12 deficiency areof optic neuritis with B12 deficiency. Zehetner C common and can be severe. With an earlyand Bechrakis NE reported a case of 40 years old diagnosis and treatment, further worsening ofpatient with white central retinal hemorrhages symptoms can be prevented. All patients oldin vitamin B12 deficiency [7]. Our patient had and young presenting with neuropsychiatricnormal fundus and there was no evidence of symptoms with or without anemia should beKayser Fleischer ring on slit lamp examination. investigated for possible Vitamin B12 deficiencyHis HIV status was also normal. A retrospective and to determine its cause and whether it mightreview conducted by Hepbur MJ, et al. (2004), it be reversible. In all cases replacement therapywas seen that, low serum B12 levels occur should be administered.commonly among HIV-infected patients, even atearly stages without overt symptoms of B12 Limitationdeficiency. Antiretroviral therapy may increaseserum B12 levels [8]. Lack of evaluation for probable cause of vitamin B12 deficiency and administration of anMRI in Vitamin B12 deficiency may produce an antipsychotic may be counted among theincreased T2-weighted signal, decreased T1- limitations of the case.weighted signal, and contrast enhancement ofthe posterior and lateral columns of the spinal Referencescord, mainly of the cervical and upper thoracicsegments; however spinal cord MRI may not be 1. Lindenbaum J, Healton E, Savage D,a highly sensitive early test for subacute Brust J, Garrett T, Podell E, Marcell P,combined degeneration [9] as symptoms may Stabler S, Allen R. Neuropsychiatricprecede any imaging abnormality. There was no disorders caused by cobalaminsignificant abnormality seen in MRI of the whole deficiency in the absence of anemia orspine in our case. In this patient several factors macrocytosis. N Engl J Med, 1988; 318:were pointing to an organic cause for psychosis 1720–172.as initial symptoms were neurologicalabnormality, in a well adjusted person, no 2. Murat Dogan, Osman Ozdemir, Ertan A.previous psychiatric history with no history Sal, S. Zehra Dogan, Pinar Ozdemir, Yasar Cesur, Huseyin Caksen. CaseInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 141Copy right © 2015, IAIM, All Rights Reserved.
Psychosis associated with Vitamin B12 deficiency ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Report: Psychotic Disorder and 7. primary hypothyroidism. J Pak Med Extrapyramidal Symptoms Associated 8. Assoc., 2008; 58(5): 258-61. with Vitamin B12 and Folate Deficiency. 9. Zehetner C, Bechrakis NE. White J Trop Pediatr, 2009; 55(3): 205-207. centered retinal hemorrhages in vitamin3. Ali Evren Tufan, Rabia Bilici, Genco Usta, b (12) deficiency anemia. Case Rep Ayten Erdoğan. Mood disorder with Ophthalmol., 2011; 2(2): 140-4. mixed, psychotic features due to vitamin Hepburn MJ, Dyal K, Runser LA, Barfield b12 deficiency in an adolescent: Case RL, Hepburn LM, Fraser SL. Low serum report. Child Adolesc Psychiatry Ment vitamin B12 levels in an outpatient HIV- Health, 2012; 6: 25. infected population. Int J STD AIDS,4. Greenfied J.G., O’Flynn E. Subacute 2004; 15(2): 127-33. combined degeneration and pernicious Locatelli ER, Laureno R, Ballard P, Mark anemia. Lancet, 1933; 2: 62. AS. MRI in vitamin B12 deficiency5. Smith A.D.M. Megaloblastic Madness. myelopathy. Can J Neurol Sci., 1999; British Medical Journal, 1960; 2(5216): 26(1): 60-3. 1840-1845.6. Jabbar A, Yawar A, Waseem S, Islam N, Ul Haque N, Zuberi L, Khan A, Akhter J. Vitamin B12 deficiency common inSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 142Copy right © 2015, IAIM, All Rights Reserved.
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