Snapshot A 50-year-old alcoholic man presents to the hospital in a florid alcohol withdrawal. He confabulates and trembles uncontrollably. He is started on supportive therapy for now. An alcohowal withdrawal score is done regularly to assess for the need for medical therapy. In the meantime, bloodwork comes back with megaloblastic anemia and increased homocysteine and normal methylmalonic acid. He is immediately started on folic acid supplementation. Introduction Folic acid (or vitamin B9) is found in leafy green vegetables Associated conditions login to view 16 more bullets Epidemiology Most common vitamin deficiency in the US Most common cause of megaloblastic anemia Can manifest after 4 months (depleted storage from liver) ETIOLOGY Pathogenesis login to view 5 more bullets Presentation Symptoms login to view 5 more bullets Physical exam login to view 2 more bullets Evaluation Peripheral blood smear login to view 3 more bullets Serum login to view 8 more bullets Also test for B12 deficiency and TSH (to rule out hypothyroidism) Differential Vitamin B12 deficiency Pernicious anemia Other causes of macrocytic anemia login to view 4 more bullets Treatment Folic acid supplementation Eat a more balanced diet login to view 1 more bullet Prevention login to view 1 more bullet Complications Neural tube defects in infant if deficient during pregnancy In the setting of a B12 deficiency, the anemia can correct with aggressive folate supplementation but the patient will still be at risk for neurological complications of B12 deficiency including peripheral neuropathy and posterior column defects due to deficiencies in myelin production Prognosis Good with supplementation