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6 B12 Deficiency Britni Hebert, PGY

7 SUMMARY ❖ B12 in the normal host ❖ B12 in the abnormal host ❖ Presentation ❖ Diagnosis ❖ Treatment

8 Normal B12 Metabolism ❖ Dietary Intake ❖ Gastric Acid and Pepsin ❖ Pancreatic Proteases ❖ Intrinsic Factor ❖ Ileal receptors

9 Normal B12 Metabolism

10 Normal B12 Metabolism

11 Abnormal B12 Metabolism

12 Presentation ❖ Alcoholics, Elderly, Vegans ❖ H/o Gastric Bypass, Elderly ❖ Neurologic complaint ❖ Blood Dyscrasias ❖ Anemia (elevated MCV in only 36%!) ❖ Macrocytosis, Ovalocytes ❖ PANCYTOPENIA ❖ Hypersegmented neutrophils

13 Heme Path

14 How to diagnose (1) Cobalamin level (1) > 300 (2) (3) < 200 (2) Methylmalonic Acid, Homocysteine

15 How to Treat ❖ Oral ❖ Nasal ❖ Sublingual ❖ Parenteral

16 What else is there? ❖T❖Treatable causes should be searched out.

17 1 slide on pernicious anemia ❖ Common ❖ Anti-IF AB ❖ Atrophic gastritis ❖ Schilling Test

18 Back to our patient ❖ Marked Hemolysis ❖ Acute presentation

19 References ❖ Dtsch Med Wochenschr Jul 29;132(27): [Pancytopenia and hemolysis--diagnosis, differential diagnosis and therapy of pernicious anemia] [Article in German] Meier N, Lipp E, Solenthaler M.Meier NLipp ESolenthaler M ❖ Physiology of B12, Up To Date ❖ Clinical Manifestations of B12 Deficiency, Up To Date ❖ Diagnosis and Treatment of B12 Deficiency, Up To Date