clinical case discussion

1. CLINICAL CASE
DISCUSSION
Dr. Neha.Newadkar
Guide : Dr.Aditya.Nesargi

2. A 35 year old female who is strict vegetarian and
has only small amounts of dairy products in diet
,came with unsteady gait since 15 days , dyspnoea
since two months. On questioning gives history of
tingling numbness in both feet .

3. ON EXAMINATION
• Glossitis++,pallor++,lemon coloured complexion.
• Pulse was 90/min
• P/A – soft , liver spleen not palpable
• CVS- Haemic murmur, heart sounds normal
• RS-NAD

4. • CNS –
• Pressure ,vibration and touch sensation reduced in B/L
lower limbs
• Plantars are extensors

5. POSITIVE FINDINGS
• Dietary history : Strict
vegetarian
• General examination : Pallor ,
glossitis , lemon
coloured complexion
• RS :
Haemic murmur, dyspnoea

6. PALLOR
Pale appearance of the skin and mucous membranes
• CAUSES :
• Anemia
• Myxodema
• Nephritis
• Collapse and shock
• Sheehan’s Syndrome
• WHERE TO SEE ??
• Lower palpebral conjunctiva
• Tongue(tip and dorsum)
• Nail beds
• Palms ,soles

7. GLOSSITIS
• Inflammation with red sore tongue
• Red swollen ,painful
• Also known as red beefy tongue
• B12 and folic acid
deficiency
• Iron deficiency anemia
(Bald tongue)
• Cirrhosis of liver
• Riboflavin deficiency

8. DYSPNOEA
• Cardiac cause :
• Congestive Cardiac failure
• Pericardial Effusion
• Acute Myocardial infarction
• Respiratory cause :
• Bronchial asthma
• Acute Bronchitis
• Pneumonia
• Chronic obstructive lung
disease
• Metabolic cause :
• Diabetic Ketoacidosis
• Uremia
• Hypokalemia
• Hematological cause :
• Severe anemia

9. TINGLING NUMBNESS• Peripheral Neuropathy:
• Vit B12 deficiency,
• Diabetes
• Isoniazid, phenytoin, lead exposure
• Renal failure, hypothyroidism
• Small cell carcinoma of lung
• Guillain barre syndrome
• Shingles (post herpetic neuralgia)
• Charcot marie tooth disease
• Lumbar canal stenosis
• Tumours
• Past history of trauma
• Compressive lesions

10. LEMON COLOURED
COMPLEXION
• Severe anemia + Mild jaundice = lemon coloured complexion
• Due to severe anemia
• Pregnancy
• Thyrotoxicosis
HAEMIC MURMUR

11. Lemon
colour
Glossitis
and
pallor
Haemic
murmur
Strict
vegeterian
Unsteady
gait,
reduced
sensation
Tingling
numbness,
extensor
plantors
Dyspnoe
a
Anemia
and SACD
due Vit
B12/folate
deficiency

12. PRIMARY INVESTIGATIONS
• CBC with Peripheral blood smear
• Reticulocyte count
• LFT

13. COMPLETE BLOOD COUNT
• Hb - 5.1 g/dL ( 12-15
)
• RBC -4.5 ×106/µL (4.5-
5.5)
• HCT- 18% ( 35-
45)
• MCV- 128 fL (80-
100)
• MCH- 40 pg (27-
• Plateletes- 1,00,000• WBC – 3×103/µL
• Neutrophil - 72%
• Lymphocyte- 24%
• Eosinophils-02%
• Monocytes – 02%

14. PERIPHERAL BLOOD SMEAR
Hypersegmented Neutrophil
Megaloblastic anemia
Iron deficiency
Myeloproliferative disorder
Chronic renal failure

15. Oval Macrocytes

16. CAUSES OF MACROCYTIC ANEMIA
Oval Macrocytosis
• Deficiency of folate or Vit B12
• Drugs :
Methoterxate ( folate
antagonists)
Hydroxyurea
Cyclophosphamide
Trimethoprim
OC pills
Round macrocytosis
• Alcoholoism
• Liver disease
• Hypothyroidism
• Myelodysplastic syndrome
• Post splenectomy

17. Basophilic stippling
Megaloblastic anemia
Thalassemia
Heavy metal poisoning
Liver disease
Hemogobinopathies

18. Megaloblastic anemia
Thalassemia
Hemolytic anemia
Post splenectomy

19. • RBC morphology:
• Anipoikilocytosis ++, Macrocytic ++, macro ovalocytes+, Few
Normblastic Normochromic, few nRBCs
• Also noted : Howel Jolly bodies, Basophilic stipplling
• WBC : Leucopenia with hyper segmented neutrophils
• Platelets : reduced to 1,00,000.

20. APPROACH TO MACROCYTIC ANEMIA (MCV>100)
Reticulocyte count
• Increased Normal /low
• Hemolytic anemia, h/o liver disease ,drugs ,
Acute blood loss hypothyroidism
NO
YES
Bone marrow examination
Normoblastic Megaloblastic Myelodysplastic Hypocelllular
Liver disease vit B12 /folate Myelodysplastic Aplastic
Hypothyroidism deficiency syndrome Anemia

21. RETICULOCYTE COUNT
• 2.5% (0.5-2.5%)
• Total Bilirubin : 1.8 ml/dl
(0.2-1.2)
• Serum conjugated bilirubin : 0.2 mg/dl
(0-0.2)
• Serum unconjugated bilirubin : 1.6mg/dl
(0.2-1.0)
• LDH 2225 IU/L
(225-450)
• SGOT 40
LIVER FUNCTION TESTS

22. TESTS FOR B 12 AND FOLATE DEFICIENCY
• Serum B12 : 90 ng/L ( 160-900ng/L)
• Serum folate : 3 ng/mL (5-16 ng/mL)
• RBC folate :110 ng /mL (>150 ng/mL)
To rule out co existing iron deficiency ,Serum iron : increased(170µg/dl)

23. BONE MARROW
• Cellularity : hypercellular
• M:E ratio 1:1
• Erythroid series :
shows hyperplasia with megaloblastic maturation with maturation arrest
• Myeloid series :
normal progressive maturation with giant metamyelocytes with fine
nuclear chromatin , eosinophilic precursors are increased.
• Megakaryocytes : large with multiple nuclear lobes and paucity of cytoplasmic
granules.
• Iron stores : grade III

29. MEGALOBLASTIC ANEMIA
Characterized by defective synthesis of DNA in all
proliferating cells most commonly resulting from lack of
folic acid or vit B12

30. VITAMIN B12 / COBALAMIN• Sources :
• Liver , dairy products
,seafish
• It is exclusively synthesized by
microorganism
• Daily requirement 2-5 µg/dl
• Stored in LIVER as
adenosylcobalamin (2 to 5mg
)
• Excreted in bile and shedding

31. • Vit B12 in food
stomach R binder
• B12 R binder complex
duodenum Intrinsic factor
IF- B12 complex + freed R binder
• Receptor-IF B12
Degradation IF
• B12-TCII
• Circulation
Receptor
TC II
Terminal ileum
epithelial cell

32. TRANSPORT OF VITAMIN B12
• Transcobalamin I
• Synthesized by
granulocytes
• Acts as storage protein
• Transcobalamin III
• Binds only small
quantities of B12 in
circulation
• Transcobalamin II
• Synthesized by liver
cells,macrophages,
hematopoetic cells
• Major transport protein
• Congenital absence
causes megaloblastic
anemia

33. FUNCTIONS OF VITAMIN B12
Homocysteine Methionine
Dietary folates
Intestinal cell Methyl FH4 FH4
Dihydrofolate reductase
dUMP dTMP DNA
synthesis
FH2
Methylene FH4
Methyl cobalamin

34. Adenosyl cobalamin
Methyl malonyl Co A Succinyl
Co A
methymalonyl Co A mutase
FUNCTIONS OF VITAMIN B 12

35. Adenosyl cobalamin
• Methyl malonyl Co A Succinyl
Co A
methymalonyl Co A mutase
Methyl malonate and
propionate
Abnormal
myelin lipids Myelin degeneration Neurological
abnormalities

36. • Diffuse and irregular degeneration of the white
matter of the central nervous system (CNS) characteristically involves
the posterior and lateral columns of the spinal cord (subacute combined
degeneration) .
• Subacute combined degeneration of posterior column presents
as:
• Symmetrical sensations of “pins and needles” of the distal extremities
• Numbness and tingling
• Loss of position sensation (difficulty with balance and gait)
• Loss of vibratory sensation (the most constant sign)

37. • Lateral column involvement presents as weakness, spasticity
and increased deep tendon reflexes.
• The brain may be affected, and the patient shows irritability,
emotional instability, or a change in personality : Megaloblastic
madness
• Neuropsychiatric disordersmay be associated with cobalamin
deficiency even without accompanying hematologic
manifestations

38. Mechanism Disorder Seen in
Decreased dietary intake Nutritional B12 deficiency Vegans
Impaired absorption
Gastric causes Atrophic gastritis
Proton pump inhibitors
Pernicious anemia
Gastrectomy
Intestinal Causes Pancreatic insufficency Zollinger Ellison syndrome
Consupmtion of luminal B12 Blind loop syndrome
Fish tapeworm infestation
Diverticulosis
Diminished IF cobalamin
receptors
Ileal bypass,ileal resection
Crohns disease
Disorders of transport Congenital TC II deficiency
Disorder of cellular B 12
metabolism
Inborn enzyme errors
Nitrous oxide inhalation

39. TESTS FOR VITAMIN B12
• CBC
• PBS
• RETICULOCYTE COUNT
• LFT
• Bone marrow aspiration and biopsy

40. SPECIAL TESTS
• Serum Vitamin B12 assay -late biomarker, lacks sensitivity and specificity
• Holotranscobalamin -( active B12)- earliest laboratary marker( <23pmol/L, normal : 23-
100pmol/L)
• Methylmalonic acid – functional marker, increases when B12 stores depleted (0-0.4micromol/L)
• Homocysteine – increased , also increased in folate deficiency (4-15micromol/L)
• Therapeutic trial- 10µg/day, increase in retic count after 4-7 days

41. Test Rationale and Advantage Disadvantage
IF antibodies specific for pernicious
anemia
70% sensitivity
Pepsinogen Mirrors gastric function Low speficity
Parietal cell antibodies Maybe + in pernicious
anemia
Very low specificity
Cobasorb Functional test, measures
increase in
holotranscobalamin
Needs further evaluation
Schilling’s test Gold standard as a
functional test for B12
absorption
False positive in with
reduced renal function

42. PERNICIOUS ANEMIA
• Failure of secretion of Intrinsic factor by stomach resulting in cobalamin deficiency
• Autoimmmune factors : gastric parietal cell auto antibodies (90%) and intrinsic
factor antibodies (50-70%)
• Hypochlorhydria
• Increased serum gastrin levels
• Complete absence of chief cells and parietal cells
• Frequently seen in females and associted with other autoimmune diseases like
Grave’s disease and Hashimoto’s thyroiditis
• Increased risk of gastric adenocarcinoma and gastric carcinoids

43. DIAGNOSIS OF PERNICIOUS ANEMIA
• Blood picture :
low Hb, elevated MCV,thrombocytopenia, leucopenia with
hypersegmented neutrophils
• Bone marrow :
hypercellular, megaloblastic with nuclear cytoplasmic
asynchrony
• Serum vitamin B12 assay : Low,essential pre requisite for diagnosis
• Anti IF antibody (75%), anti parietal cell antibody ( 90%)
• Radioactive vit B12 absorption test (Schilling’s test)
• Serum gastrin levels : Raised

44. SCHILLING’S TEST
• PART 1 : radiolabelled Vit B 12 ( 0.5 to 1µg) given orally ,after 2 hours IM dose
of unlabelled Vit B12 (1000µg)
• Measure radioactivity in 24 hour urine sample
• RESULT : Normallly : >7% of oral dose
• Abnormal : less than 7%,
seen in defective absorption in small intestine
• Part 2 : along with oral dose IF factor is also given
• RESULT : If Abnormality in part 1 corrected then – PERNICIOUS ANEMIA,
gastrectomy
• If not corrected then – Malabsorption in small intestine , Ileal disease

45. • Sources : Green leafy vegetables, fruits and liver ; easily destroyed by boiling,
cooking and canning
• Adult daily requirement : 200µg
• Absorbed in proximal jejunum and duodenum
• Transport : released in portal circulation as 5-Methyl Tetrahydrofolate
• Storage : Liver (5-20mg)
FOLATE

46. FUNCTIONS OF FOLATE
• Synthesis of thymidylate to uridylate mediated by folate : required in
DNA synthesis
• Synthesis of methionine from homocysteine
• Synthesis of purines
• Histidine catabolism ( Formiminoglutamic acid –FIGlu)

47. CAUSES OF FOLATE DEFICIENCY
• Decreased intake
• Impaired Absorption
• Increased demand
• Drugs
Nutritional deficiency
Coeliac disease
Tropical sprue
Pregnancy, lactation
Hemolytic anemias , thalassemias
Sidroblastic anemia
Leukemia ,Lymphoma
Hyperthyroidism
Methotrexate,
phenytoin,barbiturates,OC pills

48. SEQUENCE OF EVENTS IN FOLATE DEFICIENCY
• Reduction in serum folate
• Neutrophil hypersegmentation
• High excretion of FIGlu
Reduction in Red cell folate
• Appearance of megaloblastic anemia
• 2 weeks
• 7 weeks
• 14 weeks
• 17weeks
• 20weeks

49. TESTS FOR FOLATE DEFICIENCY
• Serum Folate Assay (5-21µg/L)
Microbiological and radio-isotope methods, levels below 3µg/l
suggest clinically significant folate deficiency
• Red cell Folate Assay (150-600µg/L of RBC)
More reliable indicator of tissue folates than serum folates
• Urinary FIGlu excretion increased

50. TREATMENT
• VIT B 12- given 1000µg IM dose once daily for a week , then once in 3
months
• Oral doses are equally effective
• Folate given orally 1-2 mg, duration depends on cause
• Feeling of well being in 24 hours and return of normal erthrypoesis in case of
parentral dose
• Retic starts to rise in 3 days ,peaks on 5-6th day and comes to normal by the
end of 3 weeks
• Hematocrit rises and normalises in 1-2 months
• Hypokalemia
EFFECT OF TREATMENT
SIDE EFFECT OF TREATMENT

51. MEGALOBLASTIC ANEMIAS NOT DUE TO
B12 AND FOLATE DEFICIENCY
• Myelodysplastic Syndromes
• Orotic Aciduria
• Erythroleukemia
• Thiamine responsive megaloblastic Anemia
• Antineoplastic drugs :hydroxyurea,cytaranibe