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Severe Vitamin B12 Deficiency Complicated by Profound Pancytopenia, Hemolytic Anemia, and Neuropsychiatric Changes
Background
Vitamin B12 deficiency is a well-recognized cause of megaloblastic anemia. In severe cases, it can lead to neuropsychiatric symptoms, hemolytic anemia, and pancytopenia.
Case Presentation
A 60-year-old male presented due to multiple falls and confusion. On presentation, he was markedly altered and unable to provide a history. His spouse reported a one-day history of incoordination and confusion. Physical examination revealed an ill-appearing male who was unable to follow commands with non-purposeful movements of all extremities. Initial labs showed a WBC 0.5 x103/μL, Hgb 3.6 g/dL, MCV 118.8 fL, platelets 7 x 103/μL, lymphocytes 50%, atypical lymphocytes 2%, and total bilirubin of 2.1 mg/dL (direct bilirubin 0.8 mg/dL). Further evaluation showed a reticulocyte count of 7.8 x109/L, reticulocyte 1%, and reticulocyte index of 0.7. Iron studies were unremarkable. Lactate dehydrogenase was elevated at 796 U/L and haptoglobin was undetectably low (< 20 mg/dL). Peripheral smear showed macrocytic anemia, anisopoikilocytosis, leukopenia with hypersegmented neutrophils, and thrombocytopenia; no schistocytes were noted. Additional labs showed folate of 3.8 ng/mL and an undetectably low vitamin B12 level (< 159 pg/mL). Anti-parietal cell and intrinsic factor blocking antibodies were negative. Infectious workups and serum protein electrophoresis were negative. The patient was diagnosed with severe vitamin B12 deficiency resulting in pancytopenia, hemolytic anemia secondary to intramedullary hemolysis, and neuropsychiatric changes. He was started on daily intramuscular (IM) cyanocobalamin (1000 mcg) and supportive transfusions. Over the hospitalization, his mentation returned to baseline and his cell counts stabilized.
Discussion
Vitamin B12 is an important co-factor needed for the synthesis of DNA and myelin. Vitamin B12 deficiency most commonly presents with megaloblastic anemia but neuropsychiatric manifestations can occur in severe cases. Pancytopenia occurs in ~5% of patients with B12 deficiency, whereas hemolytic anemia occurs in only ~1.5% of patients. Hemolytic anemia secondary to B12 deficiency is thought to be due to ineffective erythropoiesis causing intramedullary hemolysis. Prompt diagnosis and B12 supplementation can lead to rapid clinical recovery.
Conclusions
This case highlights the importance of considering vitamin B12 deficiency in patients with unexplained pancytopenia, hemolytic anemia, and neuropsychiatric symptoms. Early diagnosis and treatment can lead to significant and rapid clinical improvement.
Background
Vitamin B12 deficiency is a well-recognized cause of megaloblastic anemia. In severe cases, it can lead to neuropsychiatric symptoms, hemolytic anemia, and pancytopenia.
Case Presentation
A 60-year-old male presented due to multiple falls and confusion. On presentation, he was markedly altered and unable to provide a history. His spouse reported a one-day history of incoordination and confusion. Physical examination revealed an ill-appearing male who was unable to follow commands with non-purposeful movements of all extremities. Initial labs showed a WBC 0.5 x103/μL, Hgb 3.6 g/dL, MCV 118.8 fL, platelets 7 x 103/μL, lymphocytes 50%, atypical lymphocytes 2%, and total bilirubin of 2.1 mg/dL (direct bilirubin 0.8 mg/dL). Further evaluation showed a reticulocyte count of 7.8 x109/L, reticulocyte 1%, and reticulocyte index of 0.7. Iron studies were unremarkable. Lactate dehydrogenase was elevated at 796 U/L and haptoglobin was undetectably low (< 20 mg/dL). Peripheral smear showed macrocytic anemia, anisopoikilocytosis, leukopenia with hypersegmented neutrophils, and thrombocytopenia; no schistocytes were noted. Additional labs showed folate of 3.8 ng/mL and an undetectably low vitamin B12 level (< 159 pg/mL). Anti-parietal cell and intrinsic factor blocking antibodies were negative. Infectious workups and serum protein electrophoresis were negative. The patient was diagnosed with severe vitamin B12 deficiency resulting in pancytopenia, hemolytic anemia secondary to intramedullary hemolysis, and neuropsychiatric changes. He was started on daily intramuscular (IM) cyanocobalamin (1000 mcg) and supportive transfusions. Over the hospitalization, his mentation returned to baseline and his cell counts stabilized.
Discussion
Vitamin B12 is an important co-factor needed for the synthesis of DNA and myelin. Vitamin B12 deficiency most commonly presents with megaloblastic anemia but neuropsychiatric manifestations can occur in severe cases. Pancytopenia occurs in ~5% of patients with B12 deficiency, whereas hemolytic anemia occurs in only ~1.5% of patients. Hemolytic anemia secondary to B12 deficiency is thought to be due to ineffective erythropoiesis causing intramedullary hemolysis. Prompt diagnosis and B12 supplementation can lead to rapid clinical recovery.
Conclusions
This case highlights the importance of considering vitamin B12 deficiency in patients with unexplained pancytopenia, hemolytic anemia, and neuropsychiatric symptoms. Early diagnosis and treatment can lead to significant and rapid clinical improvement.
Background
Vitamin B12 deficiency is a well-recognized cause of megaloblastic anemia. In severe cases, it can lead to neuropsychiatric symptoms, hemolytic anemia, and pancytopenia.
Case Presentation
A 60-year-old male presented due to multiple falls and confusion. On presentation, he was markedly altered and unable to provide a history. His spouse reported a one-day history of incoordination and confusion. Physical examination revealed an ill-appearing male who was unable to follow commands with non-purposeful movements of all extremities. Initial labs showed a WBC 0.5 x103/μL, Hgb 3.6 g/dL, MCV 118.8 fL, platelets 7 x 103/μL, lymphocytes 50%, atypical lymphocytes 2%, and total bilirubin of 2.1 mg/dL (direct bilirubin 0.8 mg/dL). Further evaluation showed a reticulocyte count of 7.8 x109/L, reticulocyte 1%, and reticulocyte index of 0.7. Iron studies were unremarkable. Lactate dehydrogenase was elevated at 796 U/L and haptoglobin was undetectably low (< 20 mg/dL). Peripheral smear showed macrocytic anemia, anisopoikilocytosis, leukopenia with hypersegmented neutrophils, and thrombocytopenia; no schistocytes were noted. Additional labs showed folate of 3.8 ng/mL and an undetectably low vitamin B12 level (< 159 pg/mL). Anti-parietal cell and intrinsic factor blocking antibodies were negative. Infectious workups and serum protein electrophoresis were negative. The patient was diagnosed with severe vitamin B12 deficiency resulting in pancytopenia, hemolytic anemia secondary to intramedullary hemolysis, and neuropsychiatric changes. He was started on daily intramuscular (IM) cyanocobalamin (1000 mcg) and supportive transfusions. Over the hospitalization, his mentation returned to baseline and his cell counts stabilized.
Discussion
Vitamin B12 is an important co-factor needed for the synthesis of DNA and myelin. Vitamin B12 deficiency most commonly presents with megaloblastic anemia but neuropsychiatric manifestations can occur in severe cases. Pancytopenia occurs in ~5% of patients with B12 deficiency, whereas hemolytic anemia occurs in only ~1.5% of patients. Hemolytic anemia secondary to B12 deficiency is thought to be due to ineffective erythropoiesis causing intramedullary hemolysis. Prompt diagnosis and B12 supplementation can lead to rapid clinical recovery.
Conclusions
This case highlights the importance of considering vitamin B12 deficiency in patients with unexplained pancytopenia, hemolytic anemia, and neuropsychiatric symptoms. Early diagnosis and treatment can lead to significant and rapid clinical improvement.