Nutrition / Metabolism / Vitamins

Vitamin A
  • Symptoms:Night Blindness, Bilateral Dry Eyes, 
  • Signs:
    • Squamous Metaplasia with generalized hyperkeratinization, Follicular Horny Papules; 
    • Punctate Keratitis, Corneal Neovascularization, Keratomalacia (Corneal Melting); Bitot's Spot; 

  • Labs / Investigation:
    • B12 (B12 and Vitamin A gets absorbed in distal intestine)
    • Protein Level (Ocular findings will be worse if hypoproteinemia is present)
Case 1-2014: A 32-Y-O-M with Loss of Vision and a Rash (Vitamin Deficiency A, C, and D)
eBitot’s Spot in Vitamin A Deficiency NEJM 
Vitamin C
  • Symptoms: Lassitude, Fatigue, Depression, Vasomotor Instability, Limb pain (Subperiosteal Bleeding), Bleed easily (Gums / Skin) hematomas, Diet mainly soda and toaster diet, 
  • Signs: Petechia, Ecchymoses, Perifollicular Purpura, Corkscrew Hair, Follicular Hyperkeratosis (Phrynoderma), Perifollicular Hemorrhages, , sacral osteopenia, Gingival hypertrophy, Anemia
  • Labs / Investigation:
    • Ring Sign, Pelkan's Sign, Frankel's sign (White line), Lucent Line (Trummer feld zone or Scurvy Line) 
  • Diagnosis:
    • Vitamin C levels (2 methods)
      • Serum Ascorbic Acid Assay
      • WBC Ascorbic Acid Assay
  • Note: 
    • If the skin looks hyperkeratotic, Scurvy should be placed in the differential diagnosis
  • Treatment:
    • 1-2 g of Ascorbic Acid for 2-3 days; 500 mg after that for a week; Then, 100 mg daily for 1 - 3 months

Case 23-2007 (9 yr old, Rash/Ginigival Hypertrophy)
Lower Extremity Purpura (Case Challenge) JAMA 2011 
Vitamin D

Rickets Lancet 2014
Vitamin D Deficiency NEJM 2007
Osteomalacia (Image in Clinical Medicine) NEJM 
Severe Vitamin D Deficiency (Image in Clinical Medicine) Rickets NEJM 
Vitamin E
  • Progressive Motor and Sensory neuropathy, 
  • Ataxia
  • Retinal Degeneration
  • Hemolytic Anemia 
Vitamin K
  • Bleeding (external and internal organs)
Folate and B12

Thiamine  (B1)Deficiency (Beriberi)

  • High output cardiac failure 
  • Polyneuritis
B2 (Riboflavin)
  • Angular stomatitis, Glossitis (Magenta Tongue), Corneal Vascularization, Seborrheic Dermatitis 
B3 (Niacin Deficiency)
D Is for Delay NEJM 2014
  • B6 deficiency
  • Note:
Storage period of A and C is short compared to B12
  • Zinc Deficiency
  • Copper Deficiency