[Atrophy of the oro-pharyngeal mucosa caused by vitamin B12 and folic acid deficiency. Etiopathologic aspects and clinico-therapeutic problems]

BACKGROUND

By atrophy, the decrease in volume of the cell due to loss of cell substances is intended. When a sufficiently high number of cells is involved, the whole tissue or organ decreases in volume or becomes atrophic. The oropharyngeal mucous membrane can be the site of processes of mainly atrophic type whose causes can be found in various pathologies. These pathologies can be caused by alterations in the endocrin-metabolic conditions, such as vitamin deficiencies, especially of vitamin B12 and folic acid.

MATERIALS AND METHODS

Twenty-three patients who on objective examination were affected by mucous atrophies, both of the oral cavity and of the oropharyngeal area probably due to vitamin B12 and/or folic acid deficiency have been identified. Indicatively the therapies prescribed consisted of administration of N5calcium methyltetrahydrofolate for 1 month, and of pharmaceutical products containing vitamin B12, again for 1 month. After a month of therapy, the overall clinical situation of all the patients who were included in our protocol was reassessed.

RESULTS AND CONCLUSIONS

On clinical examination, 20 patient showed pink oral mucous membrane. The patients also reported disappearance of pyrotic symptoms and the laboratory tests showed values within normal limits. The erethistic ulcers on the lips had disappeared even if the vermilion did not appear fully re-epithelialized in 9 patients. The other 3 patients, who still had values under normal limits, were subjects who had undergone long-term chemotherapy. For these patients the therapy was continued for a further month. At the third check-up and careful objective examination, the lingual mucous membrane appeared pink and re-epitheliated. The patients reported disappearance of the painful oral symptoms. The laboratory tests were repeated again for all the patients and these confirmed values within normal limits for vitamin B12 and folic acid.

[Neurologic symptoms as the first manifestation of Addison-Biermer disease]

A patient was observed who came with the following symptoms persisting for six months: paraesthesia in the lower and upper limbs, weakening of muscle strength, difficulties in walking. The high value of the mean cell volume in blood morphologic examination called attention to the possibility of vitamin B12 deficiency which had not yet manifested itself as anaemia. Further studies confirmed this suggestion. As the result of the treatment with vitamin B12 full normalization of the nervous system condition and results of examinations was achieved.

Pernicious anemia. Early identification to prevent permanent sequelae

Pernicious anemia can be confidently diagnosed in a patient who has megaloblastic hematopoiesis, low serum cobalamin level, and impaired vitamin B12 absorption correctable by administering intrinsic factor. Recent studies suggest that neurologic disorders in patients with pernicious anemia are less severe than in the past, highly responsive to therapy, and seen in the absence of anemia and macrocytosis. A low serum cobalamin level in the absence of anemia, particularly in a patient with a neurologic disorder, should not be ignored.

Pancytopenia caused by unsuspected pernicious anemia complicating sickle cell beta-thalassemia

We have described a a 23-year-old black woman with sickle cell beta-thalassemia who had a urinary tract infection and who was incidentally found to be pancytopenic. Although her anemia was categorized as "normocytic, normochromic" by an electronic particle counter, evaluation of the pancytopenia confirmed unsuspected pernicious anemia. Greater vigilance and a higher index of suspicion are crucial for early diagnosis of pernicious anemia in patients with other known hemoglobinopathies.

Blood transfusion in medically treatable chronic anemia. Pernicious anemia as a model for transfusion overuse

Transfusion practice in patients with treatable, readily recognizable, chronic anemia was reviewed because such patients only infrequently need to be transfused. Pernicious anemia with hemoglobin concentration below 100 g/L was chosen as the model for this assessment. Sixty-two (51%) of 122 patients received blood transfusion, although most patients had chronic, low-grade symptoms despite their low hemoglobin levels and could have been satisfactorily managed without transfusion. Only 34 of the 122 had findings suggesting an urgent need to raise the blood cell count, but their transfusion rate (44%) was no different from that in patients without such findings. These observations in pernicious anemia indicate that transfusion of patients with medically reversible anemia is a common problem. They further suggest that current transfusion usage overemphasizes laboratory results (ie, hemoglobin levels) at the expense of clinical assessment of severity of symptoms. Improvement of current practice is needed, particularly in view of valid concerns about the serious side effects of transfusion, shortages of available blood resources, and health care costs.

Red blood cell distribution width in untreated pernicious anemia

The red blood cell distribution width (RDW) was studied in 26 unselected patients with untreated pernicious anemia. RDW changes were also sequentially followed after therapy in 12 patients. The mean (+/- 1 SD) RDW values were significantly higher in pernicious anemia patients than in controls (21.7 +/- 9.1% vs. 13.2 +/- 1.1%, P less than 0.0001). Nevertheless, 31% of the patients had normal RDWs. There were no consistent findings among those who had normal RDW. Most of them were in the early stages of deficiency, but some had advanced deficiency. Over half of those with normal RDW also had normal mean corpuscular volume (MCV). Overall, 9 of the 26 patients (35%) had normal MCV. Of eight patients whose RDW fell with therapy, some showed a steady fall while others had a transient rise followed by a progressive drop. Despite current advocacy that a high RDW is a sensitive and consistent finding in vitamin B12 deficiency, our findings show that a large proportion of untreated pernicious anemia patients have normal RDWs and that in contrast to iron deficiency, elevation of RDW is not necessarily the earliest indicator of vitamin B12 deficiency.

[Hemorrhagic diathesis as a rare lead symptom in Addison-Biermer's anemia]

It is reported on a patient with Addison-Biermer's disease who was admitted to hospital under the diagnosis of a bleeding ventricle ulcer and in whom was detected a thrombocytopenic haemorrhagic diathesis. By means of injections of vitamin B12 a complete haematologic remission was achieved. The absence of a clear increase of reticulocytes as a sequel of the blood transfusions performed before the specific therapy is discussed.