Download PDF
CC BY-NC-ND 4.0 · AJP Rep 2023; 13(01): e11-e16
DOI: 10.1055/a-2032-9737
Case Report

Misdiagnosis of Total Parental Nutrition-Related Riboflavin Deficiency: Three Case Reports of Diagnostic Error

Grant J. Shafer 
1   Division of Neonatology, Children's Hospital of Orange County, Orange, California
2   Division of Neonatology, University of California, Irvine School of Medicine, Irvine, California
,
Jose E. Abdenur
3   Division of Metabolic Diseases, Children's Hospital of Orange County, Orange, California
,
Vijay Dhar
1   Division of Neonatology, Children's Hospital of Orange County, Orange, California
2   Division of Neonatology, University of California, Irvine School of Medicine, Irvine, California
,
Michel Mikhael 
1   Division of Neonatology, Children's Hospital of Orange County, Orange, California
2   Division of Neonatology, University of California, Irvine School of Medicine, Irvine, California
› Author Affiliations Funding None.
› Further Information
Also available at
   Permissions and Reprints

Abstract

Total parental nutrition (TPN) is a critical component of neonatal intensive care. Supply shortages leading to deficiencies in TPN constituents can have devastating consequences for critically ill patients in the neonatal intensive care unit (NICU), who may be initially misdiagnosed as potential inborn errors of metabolism. Here, we present three cases of patients with prolonged TPN dependence due to intra-abdominal pathology who presented with signs and symptoms concerning for metabolic disorders and who were ultimately determined to be a result of vitamin deficiencies in the TPN after unnecessary testing and interventions had occurred. These diagnostic errors highlight the need for clinicians to maintain a high index of suspicion for nutritional deficiencies when treating patients in the NICU with potential metabolic disorders during times when TPN constituents are not available, as well as advocating to ensure that adequate supplies are maintained for this vulnerable population.

Keywords

NICU - neonatology - total parental nutrition - vitamin deficiency - diagnostic error


Publication History

Received: 27 September 2022

Accepted: 03 February 2023

Accepted Manuscript online:
10 February 2023

Article published online:
13 March 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hanson C, Thoene M, Wagner J, Collier D, Lecci K, Anderson-Berry A. Parenteral nutrition additive shortages: the short-term, long-term and potential epigenetic implications in premature and hospitalized infants. Nutrients 2012; 4 (12) 1977-1988
    CrossrefPubMedGoogle Scholar
  • 2 Shah MD, Shah SR. Nutrient deficiencies in the premature infant. Pediatr Clin North Am 2009; 56 (05) 1069-1083
    CrossrefPubMedGoogle Scholar
  • 3 Mirtallo JM, Holcombe B, Kochevar M, Guenter P. Parenteral nutrition product shortages: the A.S.P.E.N. strategy. Nutr Clin Pract 2012; 27 (03) 385-391
    CrossrefPubMedGoogle Scholar
  • 4 Mares Beltran C, Boyer MA, Denslow A, Jun A, Mikhael M, Abdenur JE. Riboflavin deficiency due to vitamin shortage in neonates with parenteral nutrition dependence. Mol Genet Metab 2022; 137 (1-2): 223-224
    CrossrefPubMedGoogle Scholar
  • 5 Balasubramaniam S, Christodoulou J, Rahman S. Disorders of riboflavin metabolism. J Inherit Metab Dis 2019; 42 (04) 608-619
    CrossrefPubMedGoogle Scholar
  • 6 Centers for Disease Control and Prevention (CDC). Lactic acidosis traced to thiamine deficiency related to nationwide shortage of multivitamins for total parenteral nutrition -- United States, 1997. MMWR Morb Mortal Wkly Rep 1997; 46 (23) 523-528
    PubMedGoogle Scholar
  • 7 Plogsted S, Adams SC, Allen K. et al; Clinical Practice Committee's Nutrition Product Shortage Subcommittee, American Society for Parenteral and Enteral Nutrition. Parenteral nutrition multivitamin product shortage considerations. Nutr Clin Pract 2016; 31 (04) 556-559
    CrossrefPubMedGoogle Scholar
  • 8 Chiong MA, Sim KG, Carpenter K. et al. Transient multiple acyl-CoA dehydrogenation deficiency in a newborn female caused by maternal riboflavin deficiency. Mol Genet Metab 2007; 92 (1-2): 109-114
    CrossrefPubMedGoogle Scholar
  • 9 Berner ES. Diagnostic error in medicine: introduction. Adv Health Sci Educ Theory Pract 2009; 14 (Suppl (Suppl. 01) 1-5
    CrossrefPubMedGoogle Scholar
  • 10 Balogh EP, Miller BT, Ball JR. , Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine. Improving Diagnosis in Health Care. Washington (DC): National Academies Press (US); 2015
  • 11 Singh H. Editorial: helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. Jt Comm J Qual Patient Saf 2014; 40 (03) 99-101
    PubMedGoogle Scholar
  • 12 Bergl PA, Nanchal RS, Singh H. Diagnostic error in the critically iii: defining the problem and exploring next steps to advance intensive care unit safety. Ann Am Thorac Soc 2018; 15 (08) 903-907
    CrossrefPubMedGoogle Scholar
  • 13 Shafer GJ, Suresh G. Diagnostic errors in the neonatal intensive care unit: a case series. AJP Rep 2018; 8 (04) e379-e383
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Shafer G, Singh H, Suresh G. Diagnostic errors in the neonatal intensive care unit: State of the science and new directions. Semin Perinatol 2019; 43 (08) 151175
    CrossrefPubMedGoogle Scholar
  • 15 Reason J. Human error: models and management. BMJ 2000; 320 (7237): 768-770
    CrossrefPubMedGoogle Scholar