Case report: Vitamin B12 deficiency and megaloblastic anemia with treatment-resistant depression and somatoform symptoms

Document Type : Case Report


1 Assistant professor of psychiatry, Psychiatry and Behavioral Research Center, Mashhad University of Medical Sciences

2 Resident of psychiatry, Psychiatry and Behavioral Research Center, Mashhad University of Medical Sciences

3 Student in medicine, Neuroscience Research Center, Islamic Azad University, Branch of Mashhad


Introduction: Megaloblastic anemias are group of disorders that usually are caused by deficiency of vitamin B12 or folate. Vitamin B12 deficiency occurs with a wide range of symptoms of hematology, neurology, gastrointestinal or psychiatry. Untreated anemia prevents the appropriate treatment even if the patient be treated properly for psychiatric disorder, will be often having inadequate response or resistance to treatment.
Case  Report: This paper presents a 33 years old woman who had experienced depression and mood lability and had been under psychiatric treatment with various psychiatric diagnoses such as borderline personality disorder, major depressive disorder and mood disorder NOS. During the six month before admission balance impairment, paresthesia, coldness and pain in lower limbs was gradually added to her symptoms. She was admitted to psychiatric hospital as a result of her suicidal thoughts and function disturbances. Complete blood count and serum B12 and folic acid levels were performed with suspicion to megaloblastic anemia. Following confirmation of diagnosis (low serum B12:90 pg ml) and treatment onset, symptoms disappeared dramatically within a few days. Patient was discharged from psychiatric hospital and in order to determine causes of megaloblastic anemia she was referred to an internist.
Conclusion: Mental disorders are prevalent in cobalamin deficiency, so even in the absence of anemia or neurological symptoms of B12 deficiency, probability of megaloblastic anemia should be considered in atypical symptoms or psychiatric disorders, refractory to conventional treatments, fluctuating and uncommon symptoms.


1.Hoffbrand AV. Megaloblastic anemia. In: Longo DL, Anthony S, Dennis F, Kasper L, Stephen L, Hauser J. (editors). Harrisons’s principles of internal medicine. New York: McGraw-Hill; 2012: 862- 872.
2. Hanna S, Lachover L, Rajarethinam RP. Vitamin B12 deficiency and depression in the elderly: Review and case report. Prim Care Companion J Clin Psychiatry 2009; 11(5): 269-70.
3. Valizadeh M, Valizadeh N. Obsessive compulsive disorder as early manifestation of B12 deficiency. Indian J Psychol Med 2011; 33(2): 203-4.
4. Sethi NK, Robilotti E, Sadan Y. Neurological manifestations of vitamin B12 deficiency. Internet J Nutr Wellness 2005; 2(1).
5. Sharma V, Biswas D. Cobalamin deficiency presenting as obsessive compulsive disorder: Case report. Gen Hosp Psychiatry 2012; 34(5): 578e7-8.
6. Kumar S. Vitamin B12 deficiency presenting with an acute reversible extrapyramidal syndrome. Neurol India 2004; 52(4): 507-9.
7. Dogan M, Ozdemir O, Sal EA, Dogan SZ, Ozdemir P, Cesur Y, et al. Psychotic disorder and extrapyramidal symptoms associated with vitamin B12 and folate deficiency. J Trop Pediatr 2009; 55(3): -7.
8. Hector M, Burton JR. What are the psychiatric manifestations of vitamin B12 deficiency? J Am Geriatr Soc 1988; 36(12): 1105-12.
9. Berry N, Sagar R, Tripathi BM. Catatonia and other psychiatric symptoms with vitamin B12 deficiency. Acta Psychiatr Scand 2003; 108: 156-9.
10. Durand C, Mary S, Brazo P, Dollfus S. Psychiatric manifestations of vitamin B12 deficiency: A case report. Encephale 2003; 29(6): 560-5.
11. Ko SM, Liu TC. Psychiatric syndromes in pernicious anaemia--a case report. Singapore Med J 1992; 33(1): 92-4.
12. Jackson IM, Doig WB, McDonald G. Pernicious anaemia as a cause of infertility. Lancet 1967; 2(7527): 1159-60.
13. Kumar Sahoo M, Avashti A, Singh P. Negative symptoms presenting as neuropsychiatric manifestation of vitamin B12 deficiency. Indian J Psychiatry 2011; 53(4): 370-1.
14. Evren Tufan A, Bilici R, Usta G, Erdoğan A. Mood disorder with mixed, psychotic features due to vitamin b12 deficiency in an adolescent: Case report.Child Adolesc Psychiatry Ment Health 2012; 6: 25.
15. Rajkumar AP, Jebaraj P.Chronic psychosis associated with vitamin B12 deficiency. J Assoc Physicians India 2008; 56: 115-6.
16. Jauhar S, Blackett A, Srireddy P, McKenna PJ. Pernicious anaemia presenting as catatonia without signs of anaemia or macrocytosis. Br J Psychiatry 2010; 197(3): 244-5.
17. Holmes JM. Cerebral manifestations of vitamin B12 deficiency. Br Med J 1956; 2: 1394-8.
18. Bolander-Gouaille C, Bottiglieri T. Homocysteine- related vitamins and neuropsychiatric disorders. Paris: Springer; 2007.
19. Davoren JB, Davoren JB. Blood disorders. In: Pathophysiology of disease: An introduction to clinical medicine. Macphee SJ, Lingappa VR, Ganong WF. (editors). New York: McGraw-Hill; 2003: 113-42.
20. Murray R, Bender D, Botham KM, Kennelly PJ, Rodwell V, Weill PA. Micronutrients, vitamins and minerals. In: Harper’s illustrated biochemistry. 29th ed. New York: McGraw Hill Medical; 2012: 467-78.
21. Kate N, Grover S, Agarwal M. Does B12 deficiency lead to lack of treatment response to conventional antidepressants? Psychiatry (Edgemont) 2010; 7(11): 42-4.
22. Werder SF. Cobalamin deficiency, hyperhomocysteinemia and dementia. Neuropsychiatr Dis Treat 2010; 6: 159-95.
23. Domisse J. Subtle vitamin deficiency and psychiatry: A largely unnoticed but devastating relationship? Med Hypotheses 1991; 34: 137-40.
24. Lindenbaum J, Healton EB, Savage DG, Brust JC, Garrett TJ, Podell ER, et al. Neuropsychi-atric disorders caused by cobalamin deficiency in the absence of anemia or macrocytosis. N Engl J Med 1988; 318: 1720-8.
25. O’Neill D, Barber RD. Reversible dementia caused by vitamin B12 deficiency. J Am Geriatr Soc 1993; 41: 192-3.
26. Martin DC, Francis J, Protetch J, Huff J. Time dependency of cognitive recovery with cobalamin replacement: Report of a pilot study. J Am Geriatr Soc 1992; 40: 168-72.