A 14 year old black female adolescent with focal neurological abnormalities complicating severe iron deficiency anemia is reported from Duke University Medical Center, Durham, North Carolina. The anemia was caused by bleeding from generalized intestinal polyposis and hereditary hemorrhagic telangiectasia complicated by nasal and gingival bleeding. Neurologic symptoms and signs began with occipital headache and neck pain, intermittent diplopia, transient right-sided numbness and weakness, and a brief syncopal episode. On admission the patient was somnolent and the neurological examination revealed bilateral VI nerve palsies, facial palsies, papilledema, and generalized muscle weakness with normal reflexes. After transfusion with packed erythrocytes and treatment with ferrous sulfate orally the facial palsy resolved within 12 hours and the VI nerve palsy and somnolence resolved by the fifth day. A normal hemoglobin was maintained by iron supplementation and the neurologic exam remained normal despite continued gingival and nasal bleeding from telangiectases. 
COMMENT. An iron deficiency anemia is reported in 23% of cases of breath-holding spells in infants and young children . The neurologic abnormalities with iron deficiency anemia may result from tissue hypoxia, increased capillary permeability, cerebral edema, and abnormal cytochrome enzyme function involved in oxygen metabolism.