Delirium As a Result of Vitamin B12 Deficiency in a Vegetarian Female

CLINICAL CASE REPORT Delirium as a result of vitamin B12 deﬁciency in a vegetarian female patient

K Mavromati and O Sentissi

Vitamin B12 deficiency can manifest with haematological, gastrointestinal and neuropsychiatric signs. The neuropsychiatric symptoms may be concurrent or precede the other symptoms. The reported case is a clinical case of delirium due to vitamin B12 deficiency in a female vegetarian patient. The patient was treated with vitamin B12 supplementation. Initially, it was difficult to diagnose this patient, who presented with delirium that could have been due to multiple causes. The finding underlines the importance of conducting a complete laboratory test panel for delirium, including the blood levels of vitamin B12.

European Journal of Clinical Nutrition (2013) 67, 996–997; doi:10.1038/ejcn.2013.128; published online 17 July 2013 Keywords: delirium; vitamin B12 deﬁciency; vegetarian

INTRODUCTION She presented moderate psychomotor retardation, confusion and Vitamin B12 deficiency is a public health problem that affects partial disorientation. She had depressed mood and anxiety, poor B20% of elderly people.1 It can manifest as haematological, concentration and difficulty in speech. She also complained of gastrointestinal or neuropsychiatric signs and symptoms sleep disturbances for the last few days and fatigue. The memory with depression, dementia, catatonia and delirium, which are deficits and insomnia had a rather acute onset over the past days considered as precursors.2–4 Studies have shown a high risk and presented a fluctuation of symptom severity over hours. of depression in elderly women with vitamin B12 deficiency A psychometric evaluation demonstrated that the patient compared with healthy female individuals.5,6 scored 27 on the Montgomery-Asberg Depression Rating Scale The lack of cobalamin is caused by food cobalamin malabsorp- (MADRS) and 22/30 on the Mini Mental Status Examination tion and pernicious anaemia. Dietary causes of vitamin B12 (MMSE). We executed a pathologic clock test, and she scored deficiency are rare and typically concern elderly people. Strict 20 on the Delirium Rating Scale Revised-98 (DRS-R-98) (cutoff vegetarianism can lead to a lack of vitamin B12 ingestion and, score: 18), indicating delirium with the presence of severe hence, its deficiency in the body.5 depressive symptoms and cognitive deficiencies. Neuropsychiatric signs and symptoms secondary to vitamin B12 Upon physical examination, the patient did not present any deficiency can be explained by the involvement of vitamin B12, as pathologic signs or symptoms apart from hypertension (up to well as folate and homocysteine, which are involved in the carbon 190/110 mm Hg) that required antihypertensive treatment with transfer metabolism (methylation) required for serotonin produc- ramipril 5 mg. The investigations revealed normal haematological tion, a crucial step in monoamine synthesis.2 and ionogram levels. Her serum vitamin B12 level was low at We report the case of a patient for whom the diagnostic and 91 pmol/l (135–700 pmol/l), and folic acid was normal at 22.2 mg/l aetiological work-up indicated delirium secondary to vitamin B12 (4.1–24 mg/l). Mrs G had a history of vitamin B12 deficiency deficiency. without presenting neuropsychiatric symptoms at the given time. The cause of the vitamin B12 deficiency was attributed to the patient’s strict vegetarianism. We conducted viral and bacterial CASE PRESENTATION screening to exclude an infectious cause of the patient’s current Mrs G was a 62-year-old widow of Argentinean origin. She was a status. The serologic results for Lyme were fairly positive for storekeeper and mother of four children and worked at her own immunoglobulin M but not immunoglobulin G. The infectious kiosk. She was vegetarian, with a history of a major depressive disease specialist proposed a retest on the subsequent month, episode 5 years ago with complete remission of the episode under and the results were negative. Other investigations, including venlafaxine treatment. brain magnetic resonance imaging, showed diffused cortical and She was admitted to the emergency department accompanied subcortical atrophy and some nonspecific abnormalities of the by the police, as she was found wandering lost and confused. She white matter concordant to the age of the patient. Neuropsychia- complained of suffering from insomnia, fatigability and poor tric tests, which were conducted 2 weeks after the beginning concentration. Following some standard physical and blood tests, of the treatment in our clinic, revealed multiple cognitive no physical explanation was found to explain her symptoms, and deficits that could be explained by either deterioration due to the patient was taken to our outpatient psychiatric crisis centre. the patient’s age or a depressive episode.

Department of Mental Health and Psychiatry, University Hospitals of Geneva, Geneva, Switzerland. Correspondence: Dr SEI Othman, Department of Mental health and psychiatry, University Hospitals of Geneva, CAPPI Jonction, 35 Rue des bains, Geneva 1205, Switzerland. E-mail: [email protected] Received 27 January 2013; revised 8 June 2013; accepted 10 June 2013; published online 17 July 2013 Delirium and vitamin B12 deficiency M Katerina et al 997 As no other cause of delirium was found, the patient lack of other possible causes confirmed our diagnosis of delirium was empirically treated with weekly injections of 1000 mgof due to vitamin B12 deficiency.10 cyanocobalamin. The vitamin B12 level was normalised 1 week In conclusion, with this case report, we would like to draw later (330 pmol/l). Treatment with escitalopram 10 mg/day was clinicians’ attention to vitamin B12 deficiency as a reversible cause gradually initiated the week following the first evaluation, as the of delirium and to the importance of conducting a complete depressive symptoms persisted. A psychiatric examination 2 laboratory work-up for delirium, including the blood levels of weeks after the first evaluation revealed an important diminution vitamin B12. of the cognitive deficiency and a partial remission of the depressive symptoms (MADRS score 22, MMSE 28/30 and DRS-R-98 4; the clock test was normalised). Four weeks after the episode, Mrs G presented premorbid CONFLICT OF INTEREST functioning levels, total remission of the depressive symptoms The authors declare no conflict of interest. (MADRS score: 4) and stable mental status; she had already resumed working on a full-time basis. REFERENCES DISCUSSION 1 Gutierrez M, Franques J, Faivre A, Koric L, Chiche L, Attarian S et al. Diagnosis of We report the case of a patient with delirium for whom vitamin B12 deficiency: a case illustrating diagnostic pitfalls. Rev Neurol (Paris) an aetiological investigation indicated a probable vitamin B12 2010; 166: 242–247. 2 Tufan AE, Bilici R, Usta G, Erdog˘an A. Mood disorder with mixed, psychotic deficiency. We emphasise the importance of conducting a wide features due to vitamin B12 deficiency in an adolescent: case report. Child Adolesc range of laboratory tests, including an evaluation of vitamin blood Psychiatry Ment Health 2012; 6: 25. levels. 3 Catalano G, Catalano MC, Rosenberg EI, Embi PJ, Embi CS. Catatonia: another The laboratory and clinical examinations we conducted neuropsychiatric presentation of vitamin B12 deficiency? Psychosomatics 1998; excluded infectious, vascular, neoplastic, metabolic and endocrine 39: 456–460. causes. Our patient had a previous major depressive episode in 4 Berry N, Sagar R, Tripathi BM. Catatonia and other psychiatric symptoms with addition to high blood pressure, leading to the hypertension vitamin B12 deficiency. Acta Psychiatr Scand 2003; 108: 156–159. diagnosis, which was considered a predisposing factor of the 5 Penninx BW, Guralnik JM, Ferrucci L, Fried LP, Allen RH, Stabler SP. Vitamin B12 delirium.7 deficiency and depression in physically disabled older women: epidemiologic evidence from the Women’s Health and Aging Study. Am J Psychiatry 2000; 157: The significant improvement in cognitive function, the return to 715–721. a normal level of consciousness and the remission of 6 Andre`s E, Vogel T, Federici L, Zimmer J, Ciobanu E, Kaltenbach G. Cobalamin her depressive and anxiety symptoms could be explained by deficiency in elderly patients: a personal view. Curr Gerontol Geriatr Res 2008; the introduction of the vitamin B12 treatment, rather than 2008: 848267. escitalopram at 10 mg/day for only 8 days.8 7 Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry, 10th edn. The remaining multiple cognitive deficits were most likely due Lippincott Williams & Wilkins, 2007, pp 323–329. to the depressive episode, primary symptoms of dementia or even 8 Machado-Vieira R, Salvadore G, Diazgranados N, Zarate Jr CA. Ketamine and the the vitamin B12 deficiency. Although the results of studies next generation of antidepressants with a rapid onset of action. Pharmacol Ther concerning cobalamin deficiency as an aetiology of cognitive 2009; 123: 143–150. 9 Kwok T, Lee J, Lam L, Woo J. Vitamin B12 supplementation did not improve deficiency and dementia are controversial, some have shown that cognition but reduced delirium in demented patients with vitamin B12 vitamin B12 supplementation can reduce the delirium associated deficiency. Arch of Gerontol Geriatr 2008; 46: 273–282. 9 with dementia in patients with low serum cobalamin levels. The 10 Harrington AL, Dixon TM, Ho CH. Vitamin B12 deficiency as a cause of delirium in positive clinical response to the substitution treatment and the a patient with spinal cord injury. Arch Phys Med Rehabil 2011; 92: 1917–1920.

& 2013 Macmillan Publishers Limited European Journal of Clinical Nutrition (2013) 996 – 997