Dr Prakash Mungli

Vitamin questions with Short case stems along

with pictures.
Case 1
A 4- year-old child has been brought to OPD with a complaint of
difficulty in walking. Physical examination reveals bowed legs, as
shown in the picture . Make a probable diagnosis for this patient.
What is the biochemical basis for this manifestation? What other
manifestations could be present in this child? How will you
confirm the diagnosis?
Answer- The child has bowed legs and appears to be suffering
from Rickets. Rickets is caused by a failure of osteoid to calcify in
growing children. It occurs due to vitamin D deficiency. Failure of
osteoid to calcify in adults is called osteomalacia.
The other manifestations in rickets could be – frontal bossing,
knock-knees, rachitic rosary along the
costochondral junctions, Harrison groove and in more severe
instances in children older than 2 years, vertebral softening leading
to Kyphoscoliosis. In the long bones, laying down of uncalcified
osteoid at the metaphysis leads to spreading of those areas,
producing knobby deformity, which is visualized on radiography
as cupping and flaring of the metaphysis.
The diagnosis is confirmed by estimating serum calcium,
phosphorus, alkaline phosphatase and vitamin D levels. All are low
except alkaline phosphatase which is high. Urinary calcium is
decreased while phosphorus is increased.

Case 2
A 32- year- old obese male has reported to the emergency with
epistaxis. History reveals that he was on “Orlistat”for weight
reduction since one year. What is the relationship between Orlistat
and epistaxis?
Answer- The patient has most probably developed vitamin K
deficiency. Absorption of vitamin K might have been decreased by
Orlistat (weight loss medication). Vitamin K deficiency is
uncommon in healthy adults but occurs in individuals with
gastrointestinal disorders, fat malabsorption or liver disease, or
after prolonged antibiotic therapy coupled with compromised
dietary intake. Impaired blood clotting is the clinical symptom of
vitamin K deficiency, which is demonstrated by measuring clotting
time. In severe cases, bleeding occurs.

Case-3
A child from a very poor socio economic background has reported
with loss of vision. Ophthalmological examination reveals dry
conjunctiva as shown in the picture. Make a probable diagnosis.
What is the underlying cause for blindness?
Answer- The child is suffering from xerophthalmia (dryness of the
conjunctiva) due to vitamin A deficiency.
The earliest symptom of vitamin A deficiency is impaired dark
adaptation, or night blindness. Severe deficiency causes
xerophthalmia, ultimately resulting in corneal ulcers, scarring and
blindness.

Case - 4
A 4 -year-old boy has been brought for consultation for bleeding
gums and hematuria. He is the 12th born in a poor family, where
one previous child died from malnutrition and dehydration in the
period of infancy. The child is fed only with cow’s milk and
biscuits. What could be the basis for these clinical manifestations?
Answer- The child is suffering from Scurvy (Vitamin C
deficiency). The incidence of scurvy peaks in children who are fed
a diet deficient in citrus fruits or vegetables. Vitamin C is
necessary for the triple-helix formation of collagen. Deficiency of
vitamin C leads to impaired collagen synthesis, causing capillary
fragility, poor wound healing, and bony abnormalities in affected
adults and children. Bleeding from gums and from other sites after
a minor trauma, are typical of vitamin C deficiency. Edema may
occur late in the disease.

Case-5
A term infant is born and does well with breast-feeding. Two days
later, the mother calls frantically because baby is bleeding from the
umbilical cord and nostrils. What is the cause of bleeding? How
can this be treated?
Answer- The child is suffering from vitamin K deficiency.
Hemorrhagic disease of newborn is caused by poor transfer of
maternal vitamin K through placenta and by lack of intestinal
bacteria in the infant for synthesis of vitamin K. The intestine is
sterile at birth and becomes colonized over the first few weeks.
Vitamin K is required for the synthesis of blood clotting proteins.
Vitamin K is the coenzyme for the carboxylation of the glutamate
residues in the post translational modifications of proteins to form
the unusual amino acid γ-carboxy Glutamic acid. γ-
Carboxyglutamate chelates calcium ions, and so permits the
binding of the blood clotting proteins to membranes.
Because of these factors, Vitamin K is routinely administered to
newborns. Deficiency of fat soluble vitamins A, E, D and K can
occur with intestinal malabsorption, but avid fetal uptake during
pregnancy usually prevents infantile symptoms.

Case-6
A 20 –year-old female has reported with glossitis and angular
stomatitis. She is a strict vegetarian and belongs to a hilly region
where cereals are traditionally dried in the open air and are thus
exposed to sunlight. She frequently gets this problem. What be the
cause for her problem?
Answer- The patient has riboflavin deficiency.
Riboflavin is found mainly in food of high nutritional value such
as meat, milk, eggs and germs of cereals.
Therefore, riboflavin deficiency is always associated with
malnutrition or hypo-alimentation. Riboflavin is photosensitive
and disintegrates when food is dried or stored in open daylight.
Riboflavin deficiency mostly manifests itself at the edge of the
mucosa. Frequently, there are painful fissures at the angles of the
mouth (angular stomatitis), fissures of the lips (Cheilosis), an
inflammation of the periglottis (glossitis) and a seborrheic
dermatitis of the nasolabial area and the eyelids .

Case-7
Which vitamin supplementation is given to a pregnant mother to
protect the fetus from neural tube defects?
Answer-Neural Tube Defects (NTDs) are birth defects of the brain
and the spinal cord. In anencephaly, upper end of the neural tube
fails to close. The brain either never completely develops or is
totally absent. In spina bifida, neural tube fails to close on lower
end. Spinal cord and back do not develop properly. Encephalocele
causes protrusion of brain or membranes through an occipital
defect of the Neural Tube.
It has been demonstrated that periconceptional (before and during
the first 28 days after conception) supplementation of women with
folic acid can decrease the risk of neural tube defects
(malformations of the brain and spinal cord, causing anencephaly
or spina bifida). Therefore, a daily intake of 400 µg folic acid in
addition to a healthy diet 8 weeks prior to and during the first 12
weeks after conception is recommended. There is evidence that
adequate folate status may also prevent the incidence of other birth
defects, including cleft lip and palate, certain heart defects and
limb malformations. To reduce the risk of neural tube defects,
cereal grains are fortified with folate in some countries.

Number 8
What is egg white injury ?

Answer-
Raw egg whites contain Avidin, a glycoprotein that strongly binds
with biotin and prevents its absorption. Thus, the ingestion of large
quantities of raw egg white over a long period can result in a biotin
deficiency. Cooking denatures avidin which prevents its binding
with biotin, hence no deficiency upon consumption of cooked
eggs.
Number -9
Maize eaters generally have skin rashes resembling pellagra. What
is its biochemical basis?

Answer- Maize lacks Tryptophan, and niacin present in it is bound

to certain components and is not bioavailable. Tryptophan
contributes as much as two-thirds of the niacin activity required by
adults in typical diets. Lack of tryptophan and niacin in maize
causes niacin deficiency manifested as pellagra. Specific food
processing, such as the treatment of corn with lime water, increases
the bioavailability of nicotinic acid in these products and can
prevent pellagra. Pellagra is characterized by a photosensitive
dermatitis. As the condition progresses, there is dementia and
possibly diarrhea. Untreated pellagra is fatal.
Case-10
The blood picture of a strict vegetarian female patient, presenting
with weakness, fissured tongue and paralysis is displayed. Make a
probable diagnosis. What will be the line of treatment?

Answer- The patient is suffering from megaloblastic anemia.

Although it is synthesized exclusively by microorganisms, for
practical purposes vitamin B12 is found only in foods of animal
origin, there being no plant sources of this vitamin. This means
that strict vegetarians (Vegans) are at risk of developing B12
deficiency. Vitamin B12 Deficiency Causes Functional Folate
Deficiency - the “Folate Trap”. Deficiency of folic acid itself or
deficiency of vitamin B12, which leads to functional folic acid
deficiency, affects cells that are dividing rapidly because they have
a large requirement for thymidine for DNA synthesis. Clinically,
this affects the bone marrow, leading to megaloblastic anemia. A
combination of folic acid and B12 is given to treat megaloblastic
anemia.
Number -11
Why is it said that babies undergoing phototherapy for
physiological jaundice are prone to develop riboflavin deficiency?

Answer- Riboflavin is stable when heated and is not easily

destroyed in the ordinary processes of cooking but it is light-
sensitive so it is degraded easily by light, that is why infants
undergoing phototherapy for jaundice become prone to this
deficiency. Loss of riboflavin is also seen if foods are left out in
sunlight or in UV light.
Because of this light sensitivity, riboflavin rapidly disappears from
milk kept in glass bottles exposed to the sun or bright daylight
(85% within 2 hours).
Case-12
A 56 – year-old male on Isoniazid Therapy for tuberculosis has
developed rashes on the exposed parts of the body. What is the
probable cause for these rashes?

Answer- The patient has developed pellagra. Prolonged treatment

with the anti-tuberculosis drug, Isoniazid, has resulted in niacin
deficiency. Isoniazid may induce a state of pyridoxine deficiency
by combining with pyridoxine and generating inactive isoniazid-
pyridoxal hydrozones, thus depleting the supply of pyridoxine.
Pyridoxine is needed in the endogenous pathway of niacin
synthesis. Thus diminished synthesis of niacin ultimately produces
pellagra, which is manifested by skin rashes as seen in the picture.