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Early-onset cases of cobalamin C defect present with multisystem disease within the first year, with severe neurologic (eg, lethargy, hypotonia, microcephaly, seizures, stroke, neurodevelopmental delay), ocular (eg, rapidly progressing maculopathy with severe photoreceptor and ganglion cell loss), hematological, renal (eg, atypical hemolytic-uremic syndrome, renal arteriolar and glomerular thrombotic microangiopathy), gastrointestinal (eg, vomiting, diarrhea, feeding difficulties), cardiac, and pulmonary manifestations (eg, apneic episodes) (147

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Travel situations often prompt temporary switches from injection to nasal spray