Medical case narrative
A 16-year-old whose blood count looked fine — his B12 didn't
What happened
A 16-year-old boy in Turkey (unnamed in the published report) had a full year of worsening symptoms before any medical cause was found: irritability, regressive behaviour, apathy, crying, truancy, forgetfulness and reduced concentration, alternating with racing thoughts, reduced sleep and appetite, and excessive online spending on his parents' credit cards — with hallucinations added in the last three months and delusions in the last month. One framing correction matters here, and both reviewers required it: the paper records no psychiatric diagnosis or treatment during that year, so this is not a story of a year spent under a wrong label. It is a year of progressive symptoms before anyone tested the basics. (The paper also notes attention problems and impulsivity reported by his teachers since second grade — part of his history, recorded here as the paper records it.)
What it looked like
A teenager in a mixed, psychotic mood state — his scores at presentation included a PANSS total of 99 — with a body quietly filing its own report: glossitis (an inflamed tongue), ataxia, rigidity in both shoulders and cog-wheel rigidity in one elbow, coordination problems, reduced arm swing, a masked face, and a positive Romberg sign.
What the labs found
Vitamin B12 deficiency due to malabsorption. His serum B12 was reported by a later review of his case as 122 pmol/L — the same level as the primary paper's figure, whose printed unit is an error and is not quoted here. His haemoglobin was 10 g/dL, but his MCV was 98 fL — inside the normal range — and his blood smear and bone marrow showed no megaloblastic changes: the blood count did not announce this deficiency, which is why it is in a library about testing rather than about looking. Endoscopy showed atrophy of the stomach lining with H. pylori colonisation, and a Schilling test confirmed malabsorption. EEG, EMG, spinal fluid, brain MRI, thyroid and liver function, electrolytes, and other tests were all normal.
What changed
He was treated with intramuscular vitamin B12, H. pylori eradication therapy — and low-dose risperidone (0.5 mg/day) for the first two weeks, a confound this entry prints rather than hides. At the week-2 visit there were no psychotic features, the Romberg sign was negative, coordination was normal, and his PANSS total had fallen to 64. The risperidone was then stopped and B12 continued as monthly injections; followed for a further six months, his psychiatric symptoms did not recur. The authors argue the risperidone dose was well below the usual range for acute psychosis and that the six symptom-free months after it stopped are the telling part — their argument, printed as theirs, alongside the shared credit.
The test that told the story
Serum vitamin B12 — ordered despite a near-normal blood count.
Sources: Tufan et al. 2012 (primary case report, all values); Naik & Dsouza, IAIM 2015 review of psychosis associated with vitamin B12 deficiency, which re-reports this same patient (B12 122 pmol/L, haemoglobin 6.2 mmol/L, MCV 98, treatment and six-month outcome).