A 3-Year-Old Girl with Eye Pain


A 3-year-old girl presents with bilateral eye pain. The history of the complaint began 3 weeks earlier with headache, photophobia, and intermittent eye pain. During this time, no erythema or discharge from the eyes is noted and no other symptoms reported.

Her medical history is positive for multiple parental-diagnosed allergies and chemical sensitivities, resulting in behavioral problems, frequent loose stools, and abdominal pain. Her parents express concern that she may have gastroesophogeal reflux disease and irritable bowel syndrome...

...A detailed review of the patient’s dietary history reveals a severely restricted diet that is limited to chickpea milk, bison meat, and salicylate-free vegetables. The patient’s 10-year-old sister was placed on a similar diet at age 1 year that resulted in scurvy and rickets by age 3 years. These findings are suspicious for possible vitamin-A deficiency, and the patient is admitted to the hospital for further evaluation and treatment. The patient’s severely restricted diet has resulted in micronutrient malnutrition. Laboratory results show hemoglobin of 7.5 g/dL, iron of 35 mcg/dL, transferrin saturation of 12%, prealbumin of 6 mg/dL, and vitamins A and C below assay limits. The patient exhibits profound oral aversion as well as behavioral difficulties as a result of her long-standing dietary restrictions, which proved very problematic as an appropriate diet was reintroduced.

Diagnosis:

Vitamin-A Deficiency

This previously healthy, unimmunized child has severe vitamin-A deficiency with xerophthalmia, corneal ulcerations, follicular hyperkeratosis, scurvy, anemia, and malnutrition. During the hospitalization, the parents requested strict adherence to a “chemical-free” environment and avoidance of medications with preservatives and artificial coloring. However, upon further investigation, the mother, a health care provider, was unable to provide any supporting evidence for the chemical sensitivities; in fact, the patient was previously seen by more than a dozen providers without substantiation of these diagnoses. Against the parents’ wishes, vitamin-A supplementation was provided to correct the deficiency and decrease her risk of serious infections from damaged skin, mucous membrane barriers, and decreased cellular immunity. Immunizations were provided, particularly the measles, mumps, rubella (MMR) vaccine, because of the significant mortality risk associated with serious measles infection and vitamin-A deficiency. After restricting parental visits, the patient’s behavior gradually began to normalize, and she was ultimately discharged to the custody of child protective services.