1
|
Aboona MB, Rapaich L, Etman A, Thomas SW. A Rare Presentation of Pernicious Anemia Manifesting as Disseminated Intravascular Coagulation. J Med Cases 2022; 13:557-560. [PMID: 36506758 PMCID: PMC9728147 DOI: 10.14740/jmc4020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/16/2022] [Indexed: 11/28/2022] Open
Abstract
Pernicious anemia is an autoimmune disorder that is characterized by the presence of autoantibodies to intrinsic factor and parietal cells which results in the inability to absorb vitamin B12. It is the most common manifestation of vitamin B12 deficiency and accounts for 20-50% of cases. Disseminated intravascular coagulation (DIC) is a clinical condition that is a complication of another process which causes the activation of coagulation. A 63-year-old female with a history of hypothyroidism presented with a 1-month history of worsening fatigue, intermittent epigastric pain, nausea, vomiting, and diarrhea. Initial laboratory findings showed severe anemia and macrocytosis with a hemoglobin of 4.3 g/dL and a mean corpuscular volume (MCV) of 138 fL. There was also a significant elevation of the D-dimer, lactate dehydrogenase (LDH), and creatinine. She received three units of packed red blood cells (pRBCs) and fluid resuscitation. A vitamin B12 level was obtained which revealed a severe vitamin B12 deficiency (< 150 pg/mL). Additional workup showed seropositivity for anti-parietal cell antibodies and intrinsic factor blocking antibodies, and an esophagogastroduodenoscopy (EGD) biopsy yielded histologic findings consistent with autoimmune gastritis. She was treated acutely with daily intramuscular B12 injections with improvement in hematologic derangements and symptomatology. Arrested erythropoiesis can lead to apoptosis and the high proliferation of immature erythroblasts results in cells that are more susceptible to impaired deoxyribonucleic acid (DNA) synthesis and results in denatured DNA. Pernicious anemia manifesting as DIC has yet to be described in the literature. Here we describe an interesting case of pernicious anemia manifesting as early DIC resulting from arrest of erythropoiesis evidenced by the international society on thrombosis and hemostasis score of 5, diagnostic for DIC. Early recognition and treatment of this reversible etiology of DIC is essential to the improvement of patient outcomes.
Collapse
Affiliation(s)
- Majd B. Aboona
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA,Corresponding Author: Majd B. Aboona, Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA.
| | - Lorna Rapaich
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
| | - Ali Etman
- Department of Family Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
| | - Sarah Woodfin Thomas
- Department of Family Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
| |
Collapse
|
2
|
Gupta P, Ahmed S, Rout NK, Yelisetti C, Panigrahi R, Behera PK, Tripathy KP, Panda SS. Co-existence of Thrombotic Thrombocytopenic Purpura and Megaloblastic Anaemia: A Case-Based Review. Mediterr J Rheumatol 2022; 33:241-246. [PMID: 36128212 PMCID: PMC9450198 DOI: 10.31138/mjr.33.2.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/06/2021] [Accepted: 04/20/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Thrombotic thrombocytopenic purpura is a rare and fatal thrombotic microangiopathy characterised by a pentad of microangiopathic haemolytic anaemia, thrombocytopenia, renal abnormalities, neurological abnormalities, and fever. Due to ineffective erythropoiesis, vitamin-B12 deficiency may rarely present as haemolytic anaemia. Case report We report a case of a 42-year-old vegetarian female presenting as vitamin B12 deficiency anaemia found to have concomitant TTP, responding to plasmapheresis, corticosteroids, and rituximab therapy. Discussion In this case of vitamin B12 deficiency with co-existent TTP, we hypothesise vitamin B12 deficiency as a contributory or precipitating factor for TTP. We reviewed similar cases in the literature to support this hypothesis. Timely detection of TTP and the initiation of treatment is of utmost importance as TTP has a high mortality when left untreated. The possible relationship with Vitamin B12 deficiency needs further exploration.
Collapse
Affiliation(s)
- Partisha Gupta
- Department of Internal Medicine, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Sakir Ahmed
- Department of Clinical Immunology & Rheumatology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Nikunj Kishore Rout
- Department of Nephrology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Chaitanya Yelisetti
- Department of Internal Medicine, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Ranjita Panigrahi
- Department of Pathology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Pradip Kumar Behera
- Department of Internal Medicine, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Krishna Padarabinda Tripathy
- Department of Internal Medicine, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Sudhansu Sekhar Panda
- Department of Internal Medicine, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| |
Collapse
|
3
|
Wood WD, Elmaghrabi A, Gotway G, Wolf MTF. The roles of homocysteinemia and methylmalonic acidemia in kidney injury in atypical hemolytic uremic syndrome caused by cobalamin C deficiency. Pediatr Nephrol 2022; 37:1415-1418. [PMID: 34854955 PMCID: PMC9160205 DOI: 10.1007/s00467-021-05372-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cobalamin C (cblC), a vitamin B12 processing protein, plays a crucial role in metabolism for the conversion of homocysteine to methionine and methylmalonyl-CoA to succinyl-CoA. CblC deficiency, an inborn error of cobalamin processing, is a rare cause of atypical hemolytic-uremic syndrome (aHUS) and results in hyperhomocysteinemia and methylmalonic aciduria. Both substances are thought to contribute to thrombotic microangiopathy (TMA) in cblC deficiency patients. However, the roles of homocysteine and methylmalonic acid (MMA) in these patients remain unclear. We want to shed more light on the contributions of homocysteine and MMA levels as contributing factors for thrombotic microangiopathy (TMA)/aHUS by a follow-up of a cblC deficiency patient over 6 years. CASE DIAGNOSIS A 27-day-old Hispanic female presented with abnormal C3-carnitine on her newborn screen, poor feeding, decreased activity, and oligouria. She was diagnosed with cblC deficiency after laboratory results revealed elevated serum homocysteine, and serum MMA along with genetic testing showing a homozygous pathogenic frameshift variant in MMACHC. The patient developed aHUS and acute kidney injury (AKI), which resolved after appropriate therapy. Over 6 years, she continued to have normal kidney function with no thrombocytopenia despite persistently elevated homocysteine and MMA levels. CONCLUSION We question the roles of homocysteine and MMA as causative of aHUS/TMA in cblC deficiency as they remained elevated during follow-up but did not result in aHUS/TMA or AKI. Hyperhomocysteinemia and/or MMA caused by other metabolic diseases do not result in aHUS/TMA or AKI. This suggests that other nephrotoxic factors may trigger aHUS/TMA in cblC patients.
Collapse
Affiliation(s)
- William D Wood
- Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ayah Elmaghrabi
- Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Garrett Gotway
- Pediatric Genetics and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthias T F Wolf
- Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
4
|
Chen P, Ramachandran P, Josan K, Wang JC. Pancytopenia and TTP-like picture secondary to pernicious anaemia. BMJ Case Rep 2020; 13:13/7/e235288. [DOI: 10.1136/bcr-2020-235288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 21-year-old man presented to the emergency department with generalised weakness, weight loss and decreased appetite for few weeks. He had evidence of severe pancytopenia and haemolysis. His peripheral smear with many schistocytes was suspicious for thrombotic thrombocytopenic purpura (TTP). He was supported with blood transfusions and daily plasmapheresis. His platelet counts worsened despite 4 days of therapy. Bone marrow biopsy was significant for hypercellular bone marrow with megaloblastic changes. Further workup revealed normal ADAMTS13 level, low vitamin B12, positive intrinsic factor antibodies and high methylmalonic acid. Diagnosis of pernicious anaemia was established and he was started on daily treatment with intramuscular vitamin B12which subsequently improved his symptoms and haematological parameters. This report highlights the importance of checking vitamin B12level in patients presenting with pancytopenia and TTP-like picture before making a diagnosis of TTP.
Collapse
|
5
|
A Rare Cause of Thrombotic Thrombocytopenia Purpura- (TTP-) Like Syndrome, Vitamin B12 Deficiency: Interpretation of Significant Pathological Findings. Case Rep Hematol 2019; 2019:1529306. [PMID: 31011456 PMCID: PMC6442445 DOI: 10.1155/2019/1529306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/27/2019] [Indexed: 12/15/2022] Open
Abstract
Thrombotic thrombocytopenia purpura (TTP) is a hematological emergency that requires rapid assessment followed by prompt initiation of therapy due to high mortality associated with delayed treatment. TTP has many causes including heritable syndromes, ADAMTS13 deficiency, and drugs-related etiologies. Profound vitamin B12 deficiency can, in rare cases, mimic TTP in presentation, and since plasmapheresis can be of limited benefit, prompt diagnosis is necessary for accurate treatment with B12. Therefore, careful analysis of all clinical signs, symptoms, and labs must be assessed. We report a patient who presented with a diagnosis of TTP, and repeat assessment confirmed a diagnosis of sever vitamin B12 (B12) deficiency with pancytopenia who was appropriately treated with B12.
Collapse
|
6
|
Tran PN, Tran MH. Cobalamin deficiency presenting with thrombotic microangiopathy (TMA) features: A systematic review. Transfus Apher Sci 2018; 57:102-106. [PMID: 29454538 DOI: 10.1016/j.transci.2018.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Cobalamin deficiency may result in hematologic characteristics similar to thrombotic microangiopathy (TMA). To facilitate diagnosis, we reviewed reported cases of acquired cobalamin deficiency presenting with TMA features (c.def-TMA). METHODS A literature search identified reports of c.def-TMA. Deficiency was defined as B12 levels of <118 pmol/L. Corrected reticulocyte counts and reticulocyte production indexes were calculated. Clinical features were presented as proportion abnormal and results summarized as medians and interquartile ranges (IQR). RESULTS Patient level data was extracted from 41 identified cases. Median age (years) was 43 (30-55) with 21/41 (51%) being female. Cobalamin deficiency was noted in 35/40 (87.5%) but fold increases in MMA and HC were 30 and 6, respectively. The etiology was pernicious anemia in 28/41 (68%) cases. Anemia was both universal and severe, with hemoglobin levels of 55 g/L (4.7-6.6). Hypersegmented neutrophils were noted in 23/37 (62%), schistocytes in 29/38 (76%) and median LDH levels 3981 U/L (2004-5467). The RPI was <3.0% in all patients. Thrombocytopenia occurred in 33/41 (80.5%) with a median platelet count of 91 × 109/L (42-112). Plasma infusion or exchange was initiated in 14/41 (34%) with associated complications in 2 cases. CONCLUSION Reticulocytopenia (RPI of <3.0%) was a universal finding that aids in differentiating c.def-TMA from other causes of hemolysis. C.def-TMA was associated with severe anemia, generally mild-moderate thrombocytopenia, and significant elevations in LDH.
Collapse
Affiliation(s)
- Phu Ngoc Tran
- Department of Internal Medicine, University of California Irvine School of Medicine, Orange, CA 92868, USA; Division of Hematology-Oncology, Chao Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, CA 92868, USA
| | - Minh-Ha Tran
- Department of Internal Medicine, University of California Irvine School of Medicine, Orange, CA 92868, USA; Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Orange, CA 92868, USA.
| |
Collapse
|
7
|
Pernicious Anemia Associated Cobalamin Deficiency and Thrombotic Microangiopathy: Case Report and Review of the Literature. Case Rep Med 2017; 2017:9410727. [PMID: 28265287 PMCID: PMC5317137 DOI: 10.1155/2017/9410727] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/22/2016] [Accepted: 12/26/2016] [Indexed: 11/17/2022] Open
Abstract
A 43-year-old Hispanic male without significant previous medical history was brought to emergency department for syncope following a blood draw to investigate a 40 lbs weight loss during the past 6 months associated with decreased appetite and progressive fatigue. The patient also reported a 1-month history of jaundice. On examination, he was hemodynamically stable and afebrile with pallor and diffuse jaundice but without skin rash or palpable purpura. Normal sensations and power in all extremities were evident on neurological exam. Presence of hemolytic anemia, schistocytosis, thrombocytopenia, and elevated lactate dehydrogenase (LDH) was suggestive of thrombotic thrombocytopenic purpura (TTP). However, presence of leukopenia, macrocytes, and an inadequate reticulocyte response to the degree of anemia served as initial clues to an alternative diagnosis. Two and one units of packed red blood cells were transfused on day 1 and day 3, respectively. In addition, one unit of platelets was transfused on day 2. Daily therapeutic plasma exchange (TPE) was initiated and continued until ADAMTS-13 result ruled out TTP. A low cobalamin (vitamin B12) level was evident at initial laboratory work-up and subsequent testing revealed positive intrinsic factor-blocking antibodies supporting a diagnosis of pernicious anemia with severe cobalamin deficiency. Hematological improvement was observed following vitamin B12 supplementation. The patient was discharged and markedly improved on day 9 with outpatient follow-up for cobalamin supplementation.
Collapse
|