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Her anemia has improved and her neurologic symptoms improved
2%
1/57
Her anemia has improved and her neurologic symptoms worsened
81%
46/57
Her anemia has worsened and her neurologic symptoms improved
Her anemia and neurologic symptoms have worsened
14%
8/57
Her cumulative symptoms remain the same
0%
0/57
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This patient has a vitamin B12 deficiency secondary to the fish tape worm Diphyllobothrium latum. Folate can correct an anemia secondary to vitamin B12 deficiency, but there will still be progression of neurologic complications without correction of B12 levels as well. Vitamin B12 deficiency may cause a macrocytic, megaloblastic anemia. Peripheral smear reveals hypersegmented neutrophils. Neurologic symptoms include paresthesias, subacute combined degeneration, and sometimes irreversible nervous system damage. Patients may experience a loss of position and vibratory sensation in the lower extremities, ataxia, and upper motor neuron signs. In late stages, the deficiency may also lead to dementia and urinary and fecal incontinence. 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 vegeterians. Folic acid may also result in a macrocytic, megaloblastic anemia. No neurologic symptoms occur with a pure folate deficiency. Due to the wide variety of causes of folate deficiency (phenytoin, sulfonamids, methotrexate, alcoholism, pregnancy), it is one of the most common vitamin deficiencies in the United States. Oh and Brown discuss vitamin B12 deficiency. Although B12 is most commonly associated with a spectrum of neuropsychiatric disorders, the role of B12 deficiency in hyperhomocysteinemia and the promotion of atherosclerosis is another system in which its importance is being explored. Deficiency may be confirmed by measuring B12 levels or methylmalonic acid and homocysteine levels which are increased early in the deficiency. Scholz et al. discuss Diphyllobothrium and its clinical importance. Up to 20 million humans are infected worldwide. Birds, fish, and mammals may all be infected. Treatment is with Praziquantel. Image A: depicts glossitis, a common symptoms in vitamin B12 deficiency. Incorrect Answers: Answers 1, 3, 4, and 5: While treatment with folate may correct the anemia in vitamin B12 deficiency, it will not correct the neurological symptoms. This patient needs treatment for the fish tape worm (Praziquantel) as well as vitamin B12 repletion to have a chance at a neurologic recovery.
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