Mood disorder with mixed, psychotic features due to vitamin b12 deficiency in an adolescent – case report

Sarah Falk

Tufan, A. E., Bilici, R., Usta, G., & Erdoğan, A. (2012). Mood disorder with mixed, psychotic features due
to vitamin b12 deficiency in an adolescent: case report. Child and adolescent psychiatry and mental
health, 6(1), 25.

Background: B12 deficiency can cause hematologic (megaloblastic anemia) neurologic

(demyelination, paresthesia), GI (anorexia, glossitis), and psychiatric symptoms (agitation, irritability,
confusion, disorientation, impaired concentration…). Affective or psychotic symptoms may also occur.
The mechanism may involve the one-carbon transfer system of B12, folate, and homocysteine. Most case
reports have focused on adults; this study is of an adolescent who presented with mixed mood disorder
with psychotic features.
Case presentation: 16 y/o male adolescent complaining of "irritability, regressive behavior, apathy,
crying, truancy" for 1 yr. Also exhibited excessive spending sprees, isolation from peers, reduced speech,
sleep, ad appetite. MSE: impaired attention/conc, insomnia, reduced working memory, hallucinations
(auditory, visual, olfactory), restricted affect, PMR. Patient also endorsed delusions of reference,
delusions of guilt, thought broadcasting. No substance abuse history. Not a vegetarian. Unremarkable
PMH and family hx. PE: glossitis, ataxia, cogwheel rigidity, bilateral coordination problems, Romberg's
sign. Negative HIV (ELISA). Normal 24hr urine copper, EEG, EMG, CSF analysis, cranial MRI, thyroid
and LFTs, pancreatic enzymes, electrolytes, PTH, ceruloplasmin, and whole blood count. BDI score of 35.
Endoscopy revealed gastric mucosa atrophy and colonization with H. pylori. B12 deficiency (166
ng/mL), ruled to be malabsorption. Patient was started on Risperidone 0.5 mg/day and IM vitamin B12
500 mcg/day, and referred for treatment of H. pylori (Clarithromycin, Lansoprazole, Amoxicillin). Upon
follow-up in second week, no psychotic features were present, Romberg's sign was negative, cerebellar
tests were WNL, extrapyramidal sx reduced, and mother reported decrease in apathy, crying, and truancy.
BDI score was 9. Vit B12 level measured at 595 pg/mL/. At the end of week 2, Risperidone was stopped
and B12 was continued via monthly injection for 3 months. Follow-up endoscopy revealed resolution of H.
pylori from gastric mucosa. Psychiatric symptoms did not return over 6 mo of follow-up.
Discussion: The low (starting) dose of Risperdal makes it likely that B12 was the primary
intervention that caused resolution of symptoms. It is unclear why B12 deficiency leads to neuropsych sx
in some patients but not others; gene polymorphisms may play a part. The pathophys of extrapyramidal
sx in patients with B12 deficiency is also unclear, but may be influenced by gene polymorphisms and
neurotransmitter variances. Larger samples are needed to determine the prevalence of extrapyramidal sx
in Vit B12 deficient patients.
Conclusion: Mood disorders with psychotic features, esp. w/ extrapyramidal sx lacking a clear
etiology, may be manifestations of B12 and/or folate deficiency in children and adolescents, and may be
amenable to treatment.