A 15-year-old girl was brought to the emergency department (ED) because she fainted.
She had started feeling ill three weeks earlier. Her mother said she had been very irritable and complained of feeling too tired to go to school. On the day she went to the hospital, she felt lightheaded getting out of bed and fainted. She also had a tingling sensation in her arms and legs, and was staggering when she walked. Physically weak, she got breathless easily. On examination, she appeared exhausted and was having trouble remembering things.
Irritable, tired, not wanting to go to school — sure sounds like “teen-itis!” But lightheadedness, tingling, difficulty walking, weakness, and breathlessness were clues that something else was going on.
The ED doctor ordered several blood tests, one of which was a complete blood count (CBC). One of the things that the CBC can identify is anemia, a deficiency of red blood cells (RBCs). RBCs contain hemoglobin, a protein that carries oxygen to the body. Anemia could have caused many of the patient’s symptoms.
Among teenage girls, a common cause of anemia is blood loss due to heavy menstrual periods. Menstrual bleeding is considered heavy when:
Bleeding lasts longer than seven days.
It soaks through one or more sanitary pads or tampons every hour for several hours.
The person passes blood clots larger than a quarter.
The blood test showed that the patient was anemic. Case closed? No. The patient’s menstrual periods were light and lasted only four days.
We need more clues.
The ED doctor noticed that the teen had lost weight, compared with earlier medical charts, and asked her what she ate. “I became a vegetarian four months ago.” What was her motive to become a vegetarian?
Teenagers can change their diets for many reasons. It is important to assess whether it’s related to an underlying emotional problem, such as an eating disorder. The patient denied intentionally losing weight and did not have issues with her body image, making an eating disorder unlikely. She said she became a vegetarian due to her compassion for animals.
The ED doctors needed to know more. There are different types of vegetarianism:
Vegetarian: does not eat any meat, including fish or poultry.
Pescatarian: does not eat meat, but eats fish and shellfish.
Lacto-ovo-vegetarian: does not eat meat or fish, but does have milk, milk products, and eggs.
Lactovegetarian: does not eat meat or eggs, but does have milk and milk products.
Vegan: does not eat animal products, including meat, fish, eggs, milk, and milk products.
The patient disclosed she was vegan. Next question: “Are you taking any vitamins?” No, she said. Ah! We found a big change in the patient’s eating habits that could have a significant impact on her health. Now we were on to something.
A blood test confirmed our suspicion: The patient was deficient in vitamin B12. Natural food sources of vitamin B12 include poultry, meat, fish, eggs, and dairy products. Vitamin B12 deficiency can occur when a person is on a vegan diet and not taking a vitamin supplement. Facts are facts: Vitamin B12 plays an essential role in red blood cell formation, cell metabolism, nerve function, and the production of DNA, the molecules inside cells that carry genetic information.
Early detection and treatment of vitamin B12 deficiency are important. It can easily be confused with something else. If left untreated, it can cause mood disturbances, intestinal problems, and nerve damage. Treatment options include:
Vitamin B12 oral medication.
Vitamin B12 intramuscular injections.
Vitamin B12 nasal gel or spray.
Is being a vegetarian safe for teenagers? The Academy of Nutrition and Dietetics supports vegetarian eating, saying that “appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases.”
Still, “dieting” in growing children and teenagers can have potential negative physical health consequences. “Nutritionally adequate” means getting adequate vitamins, iron, calcium, and calories; in growing children and teenagers, even a small reduction in calories can be associated with growth deceleration. If your child or teenager is eating a vegetarian diet, please consult with a doctor or a dietitian to make sure that diet is nutritionally adequate.
Now, back to the case. The mystery was solved, and the patient recovered with vitamin B12 supplementation. The jury has rendered a verdict for the patient: Time to go back to school. Case closed!
Niketa Raj is a fourth-year medical student at the Sidney Kimmel Medical College of Thomas Jefferson University, and Rima Himelstein is an adolescent medical physician at Nemours Children’s Hospital in Delaware.