Vitamin Deficiencies - Dr. C. Zauner

-Overall relatively uncommon in the US, but the ED population is particularly high risk
-More common in the extremes of age, the medicated, and the chronic alcohol abusers
 
Wernicke Encephalopathy
-Thiamine deficiency
-Clinical diagnosis, but frequently missed
-2 of 4 criteria
                1. Nutritional deficiency
                2. Altered mental status
                3. Ocular findings
                4. Ataxia
-Altered mental state is the most common finding
-Nystagmus is more common than opthalmoplegia
-Tx: 500 mg IV q8hr x 2d, then daily until oral tolerated
-Insufficient evidence for prophylaxis, IV not necessary and expensive!
-It’s okay to give glucose if your patient needs it before thiamine
-Always walk your patients!
 
B12 Deficiency
-B12 requires intrinsic factor for absorption
-More common in elderly, autoimmune, and those on proton pump inhibitors
-Consider in megaloblastic anemia with neurological symptoms
-Tx: IM injections
 
Vitamin D
-Required for dietary calcium and phosphorus absorption
-Majority obtained from dermal synthesis
-Low levels leads to increased PTH, which results in mobilization of Ca from the bone
-Increased prevalence of Rickets in infants due to relatively low concentration in breast milk and sunscreens
-Classically lower extremity bowing, thin bone cortex, poor growth, delayed fontanelle closure
-May progress to tetany, seizures, prolonged QT due to hypocalcemia
-If seizing or tetany, give calcium. If thinned bones, give oral vitamin D
-In the elderly – common cause of osteopenia, fragility fractures, secondary hyperparathyroidism
 
Vitamin K
-Necessary for activation of coagulation factors
-Typically in leafy greens, synthesized from gut bacteria
-Increasing in prevalence due to families refusing vaccinations
-Infants have low stores at birth, sterile gut, low concentrations in breast milk
-Classic bleeding at 2 days- 4 weeks with bleeding from mucosal surfaces
-Late presentation 3 weeks-8 months- higher percentage of ICH, blown pupil may be a sign of SDH
-Look for decreased Hct, prolonged PT
Tx: preventable with 0.5-1 mg IM at birth
There is an oral option! 2 mg orally with 1st feed, repeated at 1, 4, and 8 weeks of age
Emergency: 1 mg Vit K, 10-20 mL/kg FFP if life threatening
 
Board Review buzzwords, less likely to present as emergencies
-Night blindiness, dry eyes, keratomalacia – Vitamin A deficiency
-Idiopathic intracranial HTN – hypervitaminosis A
-Diarrhea, dermatitis, dementia (Pellegra) – Niacin deficiency (B3)
-Petechiae, perifollicular hemorrhage, bruising, corkscrew hairs (Scurvy)- Vitamin C deficiency
-Angular chelosis – Riboflavin deficiency (B2)
-Isoniazid + seizure – pyridoxine (B6)
-Spina bifida – folate deficiency

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