Current concepts of pernicious anemia

Nutritional disorders in tropical neurology

About three-fourths of the total world population live in the tropics but consume only 6% of worldwide food production and contribute 15% of the world's net revenue explaining the short life expectancy, high infantile mortality, and poor daily caloric intake; moreover, lack of clean drinking water and deficient sanitation promote water-borne infections, diarrhea, and risk of malabsorption that contribute to the prevalence of malnutrition in the tropics. One-third of the world's population consumes insufficient iodine increasing the risk for mental retardation and deafness due to maternal hypothyroidism. The main nutritional syndromes comprise protein-energy malnutrition (marasmus and kwashiorkor); nutritional neuropathies, myelopathies and neuromyelopathies, as well as specific deficiencies of vitamins and micronutrients including iodine, iron, zinc, and selenium.

Autoimmune Gastritis: Historical Antecedents, Outstanding Discoveries, and Unresolved Problems

The earliest recorded history of autoimmune gastritis can be traced to 1849 in London, when Thomas Addison described "a very remarkable form of anemia" later called pernicious (fatal) anemia (PA). This was followed by the recognition of a gastric mucosal defect suspected to have a nutritional basis, the discovery of the megaloblast that characterized the anemia, the insufficiency of a dietary extrinsic factor characterized as vitamin B12 (cobalamin), and a gastric-secreted intrinsic factor. Treatment with vitamin B12 proved curative. The link between PA and gastritis and atrophy was first confirmed histologically after immediate fixation of the stomach postmortem and later, in the 1940s, by peroral tube biopsy. The causes of gastritis remained enigmatic until the era of autoimmunity, when autoantibodies were detected first to gastric intrinsic factor and then to gastric parietal cells. Hints of a dichotomy in pathogenesis of gastritis were crystallized by the description in 1973 of Type A (Autoimmune) and Type B (later, Bacterial) gastritis. Clarification was enhanced by identification in Type A gastritis of the autoantigen of the parietal cell antibody, by the alpha and beta subunits of gastric H+/K+ ATPase, and by the highly informative experimental murine model of postneonatal thymectomy autoimmune gastritis, and in Type B of the causative role of gastric infection with Helicobacter pylori (H. pylori). A denouement will require a full understanding of (1) the origin and pathogenetic contribution of antibody to intrinsic factor; (2) the connection, if any, between H. pylori infection and Type A autoimmune gastritis; and (3) the genetic contributions to gastritis, whether due to autoimmunity or to H. pylori infection.

Initial diagnosis of anemia from sore mouth and improved classification of anemias by MCV and RDW in 30 patients

Thirty patients with a wide range of sore mouth that led to the diagnosis of iron deficiency in 12 patients, pernicious anemia in 8 patients, combined deficiency of iron and vitamin B12 in 2 patients, and anemia of chronic disease in 8 patients were investigated. The oral signs and symptoms included glossitis, glossodynia, angular cheilitis, recurrent oral ulcer, oral candidosis, diffuse erythematous mucositis, and pale oral mucosa. The values of hemoglobin in 30 patients varied from normal to severe life-threatening levels, but none had developed generalized symptoms sufficiently advanced to arouse suspicions of anemia before they visited the Oral Medicine Clinic. The aim of this paper is to describe a retrospective study of 30 patients with oral changes as the initial manifestation of nutritional deficiency or anemia of chronic diseases. Improved diagnosis and classification of anemia based on the mean and heterogeneity of red cell size will be discussed.

Clinical and laboratory features and sequelae of deficiency of folic acid (folate) and vitamin B12 (cobalamin) in pregnancy and gynecology

Classically, deficiency of folic acid (folate) or vitamin B12 (cobalamin) was recognized by the presence of a macrocytic anemia resulting from megaloblastic changes in the bone marrow. A markedly changing paradigm has identified both new mechanisms for altered folate and cobalamin status and new sequelae and clinical interrelationships that include altered mechanisms of absorption, a changing pattern of neurologic deficits, an increased risk of vascular occlusive lesions, and an important relationship with the mechanisms of neoplastic transformation. Several of these newer characterizations relate to issues of neoplasia in the nonpregnant woman and to issues in pregnancy, such as the potential for developmental abnormalities of the fetal nervous system.

Pernicious anemia with associated glossodynia

Glossitis and glossodynia are commonly seen by the dental practitioner. The awareness that these symptoms in conjunction with other oral signs indicate pernicious anemia is important for the clinician. Correct diagnosis can be made, and neurological complications avoided. Two case reports are presented and typical oral and systemic features of pernicious anemia are discussed.

Newer aspects of pernicious anemia

Although readily treatable with vitamin B12, pernicious anemia continues to captivate investigative endeavors of those interested in the pathophysiology and pathogenesis of this disorder. Notable advances have been made in understanding properties of intrinsic factor, vitamin B12-binding proteins, structure and de novo synthesis of vitamin B12, mechanism of action of vitamin B12-dependent enzymes in man, and metabolic consequences of reduced activities of these enzymes in pernicious anemia. Similarly, newer morphological observations have given information regarding pathogenesis of some of the cytological abnormalities found in megaloblasts, and recent cytochemical studies have shed light on abnormalities of nuclear and cytoplasmic constituents in vitamin B12-deficient cells. Both cellular and humoral factors may contribute to immune-mediated processes in pernicious anemia, although as yet, it has not been established with certainty that pernicious anemia is an autoimmune disorder. As we look ahead, it will be important to define the process or processes responsible for atrophic gastritis, which is the pathophysiological basis of pernicious anemia. Likewise, advances in biophysics used in the study of cell membranes, cell surface phenomena, and metallic ion transport may find applicability in the study of pernicious anemia and perhaps provide further insights into metabolic abnormalities responsible for the development of megaloblastosis.

Nonspecific stomatitis-a presenting sign in pernicious anemia

Recurrent nonspecific stomatitis may be an oral sign of pernicious anemia. Repeated examinations and blood studies are important when the cause of stomatitis is not clear on initial evaluation of a complaint of sore mouth. Three cases of pernicious anemia are presented to illustrate the similarities and differences in oral signs of pernicious anemia.

Solubilized receptor for intrinsic factor-Vitamin B12 complex from guinea pig intestinal mucosa

the absorption of vitamin B(12) in many animals requires its prior association with intrinsic factor (IF) and attachment to a specific receptor in the intestine. Employing Triton X-100, we have solubilized from guinea pig ileum a factor that binds intrinsic factor-vitamin B(12) complex (IF-B(12)). This binding factor was soluble to the extent that it was not sedimented by centrifugation at 100,000 g for 1 h and was small enough to enter the included volume of a Sepharose 4-B column. Furthermore, the ileal extract contained no microfine particles of membrane upon electron microscopic search. When a portion of the extract was incubated with a mixture of gastric juice and (57)Co-labeled vitamin B(12), a portion of the radioactivity was excluded from a Sephadex G-200 column. When gastric juice from a patient with a congenital abnormality of IF that prevented its binding to intestine was substituted for normal human gastric juice, radioactivity was not excluded from the gel, indicating failure of this abnormal IF-B(12) to bind to the intestinal extract. These data suggested the presence of a specific binder of IF-B(12) in the ileal mucosal extract. The reactions of normal IF-B(12) with the solubilized binding factor and with the membrane-bound "receptor" had several characteristics in common, including calcium dependence, temperature independence, and pH optimum near neutral. Extracts from the distal intestine showed more activity than did those from the proximal. The solubilized binding facter seemed specific for IF-B(12) in that it was not blocked by prior incubation with excesses of either free vitamin B(12) or IF. Binding activity of the extract was decreased by incubation at pH 2.0, by heating to 56 degrees C, and by incubation with chymotrypsin and dithiothretiol. Incubation with trypsin, neuraminidase, and sulphydryl blockers did not affect it. The Triton X-100 extract of guinea pig ileal mucosa contains a specific binding factor that probably is the receptor for IF-B(12). This appears to be a protein with function dependent on peptide and disulphide linkages.