9.6 Vitamin deficiency Flashcards
You are asked to review a 56-year-old male. He has presented to your practice complaining of a worsening rash and ongoing diarrhoea. The rash is erythematous and bilaterally symmetrical over his upper and lower limbs over sun-exposed areas. He reports that it is very tender and has a burning sensation. As well, he complains of ongoing nausea, vomiting and watery diarrhoea. He also reports that he is finding it harder and harder to concentrate at work and that he is increasingly forgetful. He reports that he normally leads a very healthy lifestyle, having taken up frequent cycling and a strict vegan diet 2 years ago. What is the most likely diagnosis?
- Pernicious anaemia
- Beriberi1
- Pellagra
- Scurvy
- Wernicke–Korsakoff syndrome
Pellagra: Dermatitis, diarrhoea, dementia/delusions, leading to death
Important for meLess important
Vitamin deficiencies should be suspected in those with reduced vitamin uptake/absorption, including those with malnutrition, strict diets or bowel disease. In this case, this veganism is the cause of his nutritional deficiency.
Pellagra is a deficiency of vitamin B3, niacin.
Primary pellagra is due to a diet that is poor in niacin, as described in this case. The patient exhibits the characteristic sunburn-like dermatitis rash, diarrhoea and cognitive deficit (dementia/delusion).
Beriberi is due to a thiamine (vitamin B1) deficiency and can be further categorized into wet beriberi (presenting with tachypnoea, dyspnoea and pedal oedema) and dry beriberi (presenting with pain, paresthesia and confusion). Wernicke–Korsakoff syndrome is a subtype of dry beriberi.
Scurvy is due to vitamin C deficiency. It presents with anaemia, bleeding gums and bruising/petechiae of the skin.
A patient requires calcium supplements. What will facilitate the absorption of calcium?
- Ascorbic acid
- Colecalciferol
- Hydroxocobalamin
- Pyridoxine
- Phytomenadione
The correct answer was Colecalciferol
Mrs Smith has been taking 800 units of ergocalciferol for 2 weeks now because she has a lack of vitamin D.
She develops nausea and has now vomited. What is the likely reason for this?
- The vitamin D may have led to an increase in serum calcium causing the symptoms
- The vitamin D therapy may have decreased serum calcium causing the symptoms
- The preparations of ergocalciferol are generally not well tolerated
- If ergocalciferol is given without calcium, it may cause this symptom
- These symptoms are unrelated to Mrs Smith’s therapy
The correct answer was The vitamin D may have led to an increase in serum calcium causing the symptoms
Mrs A comes into your pharmacy. She tells you that her 5 year old daughter tires easily, is reluctant to walk and it looks like her legs are bowed.
Vitamin A
Vitamin B1
Vitamin B3
Vitamin B12
Vitamin C
Vitamin D
Vitamin E
Vitamin K
Vitamin D
The child’s symptoms are indicative of rickets, as a result of vitamin D deficiency.
Mr D comes into your pharmacy. He tells you that he has recently been to visit his 93 year old father. He express his concern regarding his father’s health over the past 3 months. He says that he has swollen and bleeding gums and that he has developed red spots on his shins. He has also noticed a few bruises on his body.
Vitamin A
Vitamin B1
Vitamin B3
Vitamin B12
Vitamin C
Vitamin D
Vitamin E
Vitamin K
Vitamin C
His fathers symptoms are indicative of scurvy (vitamin C deficiency). Although rare, it could occur in very elderly patients who may find it harder to cook or maintain a healthy diet.
For each of the following questions, select the vitamin or mineral which is the correct answer. Each option may be used once, more than once or not at all.
This helps the absorption of calcium in the gut.
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc
The correct answer was Vitamin D
Vitamin D is needed for the body to absorb calcium effectively. Unlike other vitamins, we do not need to get vitamin D from food. Most of the vitamin D we have is made by our own bodies. It is made in the skin by the action of sunlight. This is a good thing because most foods contain no, or very little, vitamin D naturally.
You should advise pregnant patients to avoid liver products due to the fact they contain this.
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc
Retinol
Retinol is vitamin A which is found in large volumes in liver products, which can be harmful to the unborn baby.
A 35-year-old female suffered from a history of pernicious anaemia (in which a lack of gastric intrinsic factor results from an autoimmune gastritis). This caused the malabsorption of a vitamin and subsequently megaloblastic anaemia.
Vitamin E
Vitamin K
Vitamin A
Vitamin B12
Calcium
Vitamin B1
Phosphate
Vitamin B6
Vitamin B12
1 mg of this vitamin could be given as a single intramuscular injection at birth to prevent serious bleeding, including intracranial bleeding.
Vitamin K
Wernicke’s encephalopathy secondary to chronic alcoholism is treated in the long term with the oral administration of this.
Vitamin B1
A 45-year-old woman was commenced on treatment for a tuberculosis infection, 3 months ago. She has since developed a burning sensation at the base of her feet.
Which of the following medications may have caused this new ‘burning sensation’?
- Rifampicin
- Isoniazid
- Pyrazinamide
- Ethambutol
- Amoxicillin
Isoniazid therapy can cause a vitamin B6 deficiency causing peripheral neuropathy
TB drugs have a variety of side effects, many of which are widely tested in medical school examinations. This patient is reporting evidence of a peripheral neuropathy which can be caused by the vitamin b6 deficiency that can result with Isoniazid therapy. Usually, prophylactic pyridoxine hydrochloride is prescribed at the same time as Isoniazid to prevent the peripheral neuropathy.
You have identified someone who has a folic acid deficiency.
What are the next steps?
Folic acid:
- 2.7 to 17.0 nanograms per milliliter (ng/mL)
- For most people, treatment will be required for 4 months.
- However, folic acid may need to be taken longer (sometimes for life) if the underlying cause of deficiency is persistent
Cautions and contraindications:
Do not prescribe folic acid to people with:
- Pernicious anaemia or undiagnosed megaloblastic anaemia (without vitamin B12) — this may precipitate subacute combined degeneration of the spinal cord. Should be loaded with vitamin B12 first.
Prescribe folic acid with caution to people:
- With coronary stents.
- Who may have folate-dependent tumours
- Undergoing haemodialysis – folic acid is removed by haemodialysis.
Adverse effects of folic acid include:
- GI: abdominal distension, flatulence, anorexia, nausea.
- Immune system: allergic reactions, including erythema, rash, pruritus, urticaria, dyspnoea, and anaphylactic reactions (including shock).
Drug interactions that occur with folic acid include:
- Carbamazepine — levels may be reduced if taken concurrently with folic acid. Monitor carbamazepine concentrations and adjust the dose accordingly.
- Fluorouracil — levels may be increased producing toxicity. Avoid concurrent use with folic acid.
- Phenobarbital — levels may be reduced if taken concurrently with folic acid. Monitor phenobarbital concentrations and adjust the dose accordingly.
- Phenytoin — levels may be reduced by 16–50% if taken concurrently with folic acid. Monitor phenytoin concentrations and adjust the dose accordingly.
- Primidone — levels may be reduced if taken concurrently with folic acid. Monitor primidone concentrations and adjust the dose accordingly.
- Sulfasalazine — absorption of folic acid may be reduced. Monitor blood counts closely if folic acid is given concurrently with sulfasalazine.
A 24-year-old woman attends her GP feeling more fatigued than usual. She has a past medical history of epilepsy, polycystic ovarian syndrome, and depression. She also suffers from occasional irritable bowel syndrome with constipation (IBS-C). Her GP sends a full blood count which shows:
Hb101 g/L(115 - 160)
Platelets350 * 109/L(150 - 400)
WBC8.0 * 109/L(4.0 - 11.0)
Mean Cell Volume100 fl(80 - 96)
Ferritin150 mcg/L(12 - 300)
Folate1.2 ng/ml(>4)
Out of her medications listed below, which is likely to have caused this presentation?
- Combined oral contraceptive pill
- Fluoxetine
- Ibuprofen
- Movicol
- Phenytoin
Phenytoin is a cause of folic acid deficiency
This patient has symptoms of anaemia (lethargy) and has a full blood count which shows macrocytic anaemia with a low folate level. It is most likely that phenytoin for her epilepsy has caused her symptoms. Folate deficiency associated with anti-epileptic medications is complex, however, it is believed that phenytoin induces intestinal pH changes affecting the enterohepatic circulation of folate.
The combined oral contraceptive pill is not associated with anaemia or macrocytic anaemia. It is likely to be used by this patient due to her diagnosis of polycystic ovarian syndrome.
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is used in the management of depression. It should be used with caution in epileptic patients, however, it is not contraindicated. While not associated with anaemia, it can be associated with lethargy, sleep disorders, and QT prolongation.
Ibuprofen is not associated with anaemia or lethargy and, therefore, is the incorrect answer.
Movicol is a laxative that is used for the relief of constipation. It has likely been prescribed for her IBS-C. Laxative use can occasionally be associated with vitamin D deficiency - this is mainly due to laxative abuse or excessive consumption. It is not typically associated with folic acid deficiency unless there is a severe reduction in absorption of foods.
A 34-year-old woman of Chinese Han ethnicity telephones her GP to discuss her pregnancy which was planned and is at an estimated 6-weeks gestation. She smokes 10 cigarettes/day and has a body mass index (BMI) of 31 kg/m². She suffers from mild asthma only, which is well-controlled with inhaled beclometasone. The GP prescribes folic acid 5mg daily and advises the patient to continue this for the first 12-weeks of her pregnancy.
Which of the following is an indication for high-dose folic acid for this patient?
- History of asthma
- Patient’s age
- Patient’s body mass index (BMI)
- Patient’s ethnicity
- Smoking status
Pregnant obese women (BMI >30 kg/m2), should be given high dose 5mg folic acid
Folic acid intake is important in the 1st trimester of pregnancy to help prevent neural tube defects (NTD). For most pregnant patients, 0.4mg daily in the first 12 weeks of pregnancy is sufficient. However, patients with a BMI of ≥30 kg/m² should be provided with 5mg daily for the first 12 weeks of pregnancy.
In addition to patients with a BMI of ≥30 kg/m², folic acid should also be prescribed at a 5mg daily dose for those with diabetes, sickle cell disease (SCD), thalassaemia trait, coeliac disease, on anti-epileptic medication, personal or family history of NTD, or who have previously given birth to a baby with an NTD. Ideally, folic acid should be commenced whilst trying to conceive as this will further minimise NTD risk.
History of asthma, smoking, patient age, and Asian ethnicity are not indications for high-dose folic acid prescribing in pregnancy.
Smoking in pregnancy is a risk factor for prematurity, low birth weight, and cleft lip/palate. There is a possible association between smoking and NTD risk, though at this time of writing high dose folic acid prescribing for pregnant smokers is not recommended.
Both asthma and the extremes of maternal age (young and old) may also carry some risk of an NTD, but this remains to be established and high dose folic acid prescribing for these patient groups is not currently recommended.
Alongside folic acid, NICE recommend all pregnant patients take vitamin D 10mcg (400 units) daily. This should be continued throughout the duration of their entire pregnancy.
A 46-year-old woman has come into her GP. She is planning on becoming pregnant, and would like advice about simple lifestyle changes and medications she should be taking, and the GP mentions that the woman should be taking the high dose (5 mg) folic acid. Which of the following is a reason for taking high dose folic acid?
- Age >30
- BMI >30
- Iron deficiency anaemia
- Osteomalacia
- Twin pregnancy
Pregnant obese women (BMI >30 kg/m2), should be given high dose 5mg folic acid
Folic acid is taken during pregnancy to reduce risk of neural tube defects (NTD). The only above reason for needing high dose folic acid is obesity. Other reasons include previous pregnancy with NTD or family history of NTD, as well as use of antiepileptic drugs, coeliac disease, diabetes, and thalassaemia trait.
