P3A047: Depression, Petechiae and Pasta

Introduction: This case presents the possible re-emergence of rare nutritional deficiencies and underlying concomitant psychiatric disorders, exacerbated by the COVID-19 pandemic and an overwhelmed mental health system.

Case Description: A 17 year old, thin (BMI 16.33), developmentally normal female with a complicated psychiatric history was admitted to the inpatient ward for symptomatic anemia (Hgb 6.9) and concern for suicidal ideation, triggered by the COVID-19 pandemic. She also had gingivitis and a diffuse lower extremity petechial rash with overlying corkscrew hairs, that had been evaluated by numerous providers over the past months.

She had an extremely limited diet of primarily simple carbohydrates, consisting of pasta with butter. She denied any alcohol consumption, vomiting, diarrhea or GI symptoms. Labs were notable for HgB of 6.9 g/dL (11.6-15.2) with normal platelets and MCV. Further nutritional studies demonstrated low iron, iron binding capacity, prealbumin, and folate. CMP, LDH, ferritin, zinc, methylmalonic acid, thiamine, vitamin D,25-OH, and niacin were within normal limits. COVID-19 and Influenza were negative. Serum vitamin C level was also obtained.

Based on her presentation and labs, the presumed diagnosis of scurvy was made. Upon 24-48hrs of initiating high dose vitamin C supplementation, she reported significant improvement in her gum pain, myalgias, rash, and overall improved mood. Her serum vitamin C level resulted at < 5 umol/L (23-114), confirming the clinical diagnosis of Hypovitaminosis C.

Discussion: This case report highlights the importance of early identification of concomitant nutritional deficiencies when presented with general complaints and psychiatric diseases, particularly in high-risk youth in the aftermath of the COVID-19 pandemic.

Hypovitaminosis C can occur after 1-3 months of inadequate dietary intake, as seen in our patient. Most providers tend to consider nutritional deficiencies in the differential diagnosis in children with autism spectrum disorder, developmental delay, or highly restrictive food intolerances. This case demonstrates that hypovitaminosis C can occur broadly across the general pediatric population.

A history of refractory or chronic psychiatric conditions should prompt providers to evaluate for nutritional status, as these conditions are associated with disordered eating [16]. The COVID-19 pandemic has increased breaks in care of adolescents with psychiatric illnesses [16], with one meta-analysis demonstrating an approximately seven times higher proportion of depression during the COVID-19 pandemic [12]. Other studies have shown significant increases in inpatient admissions for restrictive eating disorders during the pandemic, which is likely to continue increasing [17, 18, 19].

Conclusion: This case serves as a reminder for providers to consider nutritional deficiencies in the differential, with paid attention to growth chart trends. This may help identify patients at high risk of concomitant nutritional deficiencies where prompt initiation of appropriate nutritional repletion may be of therapeutic benefit [5, 10, 15].