Review Question - QID 104747

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B12 Deficiency QID: 104747 (M2.HE.15.107)

QID 104747 (Type "104747" in App Search)

A 51-year-old white female presents to her primary care physician for a regular check-up. She endorses eating a healthy diet with a balance of meat and vegetables. She also states that she has a glass of wine each night with dinner. As part of the evaluation, a complete blood count and blood smear were performed and are remarkable for: Hemoglobin 8.7 g/dL, Hematocrit 27%, MCV 111 fL, and a smear showing macrocytes and several hypersegmented neutrophils. Suspecting an autoimmune condition with anti-intrinsic factor antibodies, what other finding might you expect in this patient?

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High serum TSH

56%

14/25

Psorasis

0/25

Cheilosis

20%

5/25

Bleeding gums

2/25

Abdominal colic

12%

3/25

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The patient in this vignette most likely has pernicious anemia. These patients are at increased risk of other autoimmune conditions such as vitiligo, Hashimoto's thyroiditis, and neurologic abnormalities.

Vitamin B12 deficiency may cause a wide range of disorders including a macrocytic, megaloblastic anemia, neurologic symptoms including paresthesias, subacute combined degeneration of the spinal cord, and sometimes irreversible nervous system damage, ataxia, and upper motor neuron signs. Patients may also present with stomatitis and glossitis. Causes include malabsorption as seen in celiac disease as well as pernicious anemia, bypass surgery, and the fish tape worm Diphyllobothrium latum. Also suspect this deficiency in strict vegetarians after an extended period of time (to keep B12/Folate deficiency straight, remember that FOLate is found in FOLiage, and B12 the is the other one, found in animal products).

Langan and Zawistoski review vitamin B12 deficiency. Work-up for vitamin B12 deficiency should include complete blood count and vitamin B12, homocysteine, and methylmalonic acid levels. The authors state that both monthly IM and high-dose PO vitamin B12 administration lead to similar improvements in B12 levels regardless of etiology, specifically including malabsorption states.

Kim et al. investigated the efficacy of oral B12 replacement in patients who underwent total gastrectomy for gastric cancer. They showed that there was no significant difference between groups receiving IM versus PO vitamin B12, with both groups exhibiting improvement in B12 levels. Twenty-eight of 29 total gastrectomy patients who received oral B12 supplementation experienced neurologic symptom relief.

Illustration A shows an example of a hypersegmented neutrophil seen with megaloblastic anemia in general and specifically with B12 deficiency. Illustration B shows a hand with vitiligo.

Incorrect Answers:
Answer 2: Vitiligo, not psorasis, is seen with B12 deficiency.
Answer 3: Cheilosis is seen with B2 deficiency, not B12.
Answer 4: Bleeding gums are classic for scurvy, or vitamin C deficiency.
Answer 5: Abdominal colic is seen with lead poisoning.

ILLUSTRATIONS: