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Vegan Diet and Vitamin A Deficiency

A 6-year-old boy was transferred for tertiary ophthalmic care. He had been hospitalized at an outlying facility with a chief complaint of “swollen, red eyes” and loss of vision. His diagnoses were listed as ocular injury of unknown etiology, electrolyte imbalance, and medical neglect. His parents believed his ocular problem developed 3 months previously, when ocular irritation was discovered after the child’s eyes were splashed with milk at school. They suspected a milk allergy because the child had never been exposed to dairy products, as he was a vegan. An examination at an emergency room soon after revealed edematous eyelids, injected conjunctiva, and “rosy” cheeks. Oral diphenhydramine was prescribed, but the child and his mother left the facility before his medical evaluation was completed. The parents were telephoned and advised to continue treatment with diphenhydramine for 5 days. Advice to follow-up with a primary care physician was not heeded. His parents removed him from kindergarten, because they feared additional exposure to milk products. The child’s symptoms worsened and the parents sought attention from an oriental medical arts practitioner, who prescribed herbal eye drops. Progressive tearing, discomfort, and photophobia developed in the 2 months before admission. The previously active child lost interest in play and became somnolent. In the weeks before admission, he was bed-bound and could not see. The boy had been in good health with no previous visual problems. He was reported to have completed all vaccination series but was not under the regular care of a physician. The family’s diet excluded all dairy and egg products. He had no known drug allergies. On admission to an outlying hospital, his weight of 21 kg fell on the 50th percentile growth curve for age; his height of 112 cm placed him in the 25th percentile. He had apparent central obesity. Notable were his brittle hair; dry, foul-smelling, scaly skin; and poor oral hygiene. He was irritable and had intense blepharospasm. His blood work revealed sodium 127 mEg/L, potassium 2.9 mEg/L, hemoglobin 10.7 g/dL, hematocrit 31 and prealbumin 11 mg/dL (normal range 10–40 mg/dL). A diagnosis of global nutritional deficiency including hypovitaminosis A was considered, but it was assumed that he received adequate vitamin A