versión impresa ISSN 1516-4446
Rev. Bras. Psiquiatr. vol.32 no.2 São Paulo jun. 2010
CARTAS AOS EDITORES
Scurvy, anemia and malnutrition secondary to obsessive-compulsive disorder
Escorbuto, anemia e desnutrição secundários ao transtorno obsessivo-compulsivo
There are several reports in the literature concerning nutritional complications in patients with mental disorders, including eating1 and psychotic2 disorders. Herein we report a rare case of scurvy, anemia and malnutrition secondary to obsessive-compulsive disorder (OCD).
A single, retired, 61-year-old Caucasian male sought medical assistance due to a 30-day history of hyporexia, asthenia, gingival bleeding and ecchymoses. He was very thin and pale, with teeth in poor condition, gingival swelling, a pyogenic granuloma in the hard palate, ligament laxity of the left patellar tendon and several petechiae and bruises on the arms and legs. He was hospitalized after diagnoses of severe malnutrition, scurvy and multiple deprivation anemia, confirmed by laboratory tests. On admission, he reported a diagnosis of "schizophrenia" and was observed presenting "soliloquies". However, he had never presented any psychotic symptom or received psychiatric treatment. Replacement of ascorbic acid, folic acid, ferrous sulfate and vitamin B complex was initiated and he was referred for psychiatric evaluation.
The patient reported an extremely restricted diet lasting about 12 years: each meal consisted solely of a porridge made of cornstarch wafer, milk and sugar. Although he enjoyed vegetables and meat, he was afraid of eating contaminants that might be present in nonindustrialized foods and consequently become ill and suffer till death. He also reported ordering/symmetry and checking rituals, and repeated washing of hands and utensils to avoid the ingestion of "viruses and bacteria". The patient frequently repeated his phrases to make sure that he had spoken properly (possible "soliloquies"). Also, when his left patella was photographed, he requested a photo from the opposite side so as to "feel right". In a clinical meeting, OCD diagnosis was confirmed.
He was a quiet child, with exaggerated fears of "bandits", diseases and contamination. He had studied until high school, worked, but never got married. He denied substance use or psychiatric familial history.
Paroxetine was introduced (20mg/day), although he was afraid of "getting sick" by taking "numerous drugs". After 26 days he was discharged, but he did not attend the psychiatric follow-up appointments.
This case illustrates the importance of OCD diagnosis, which is often a secret condition that can lead to other serious health problems, such as rectal prolapse3 and loss of vision.4 Scurvy, which occurs as a result of ascorbic acid deficiency, is a rare condition nowadays. It has been reported as a complication of other psychiatric disorders,1,2 but only once related to OCD.5 Since vitamin C helps iron absorption, its lack may have contributed to the patient's anemia, in addition to blood loss. Capillary fragility, delayed healing, and impaired collagen synthesis also result from this deficiency.5
This case demonstrates that OCD safety-seeking behaviors may in fact be counterproductive, since the patient got sick precisely because of his obsessive fear of getting sick. General practitioners and psychiatrists should work together to ensure early diagnosis and comprehensive treatment of cases such as this one. Unfortunately, this patient abandoned treatment, which could lead to recurrence of the nutritional problems, since the primary condition was not treated.
Marcelle Y. Yaegaschi, Albina R. Torres
Department of Neurology, Psychiatry and Psychology,
Botucatu Medical School, Universidade Estadual Paulista
(UNESP), Botucatu, SP, Brazil
1. Christopher K, Tammaro D, Wing EJ. Early scurvy complicating anorexia nervosa. South Med J. 2002;95(9):1065-6. [ Links ]
2. Arron ST, Liao W, Maurer T. Scurvy: a presenting sign of psychosis. J Am Acad Dermatol. 2007;57(2 Suppl):S8-10. [ Links ]
3. Henry JB, Drummond LM, Kolb, P. Obsessive-compulsive disorder and rectal prolapse. Eur J Gastroenterol Hepatol. 2006;18(7):797-8. [ Links ]
4. Torres AR, Domingues MS, Shiguematsu AI, Smaira SI. Loss of vision secondary to obsessive-compulsive disorder. Gen Hosp Psychiatry. 2009;31(3):292-4. [ Links ]
5. Mak WM, Thirumoorthy T. A case of scurvy in Singapore in the year 2006. Singapore Med J. 2007;48(12):1151-5. [ Links ]