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Taylor L, McCaddon A, Wolffenbuttel BHR. Creating a Framework for Treating Autoimmune Gastritis-The Case for Replacing Lost Acid. Nutrients 2024; 16:662. [PMID: 38474790 DOI: 10.3390/nu16050662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Autoimmune gastritis (AIG) is characterized by the destruction of gastric parietal cells, resulting in hypochlorhydria and eventual achlorhydria, as oxyntic glands in the corpus are destroyed and become atrophic. The permanent loss of gastric acid has many impacts-both theoretical and documented. The most concerning of these are hypergastrinemia and increased N-nitroso compounds, both of which increase the risk of gastric cancers. While known deficiencies of B12 and iron are often replaced in AIG, acid is not. Moreover, patients with AIG are often prescribed acid suppression for a stomach that is decidedly no longer acidic, worsening the sequelae of gastric atrophy. Betaine hydrochloride (BHCL) is a short-acting acidifying agent, available over the counter in capsule form. Mealtime acid supplementation has an historic basis and could ameliorate many AIG-related gastrointestinal symptoms. Theoretically, acidification could also reduce the potential for hypergastrinemia and the production of N-nitroso compounds, consequently reducing the risk of gastric cancers. Supplemental vitamin C may also help in preventing gastric N-nitroso formation, regardless of the gastric pH. This narrative review describes the functions of gastric acid in gastrointestinal and immune health, documents the effects of hypochlorhydria in AIG, and proposes potential options for safely re-establishing the acid milieu of the stomach for patients with AIG.
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Affiliation(s)
- Lori Taylor
- Faculty of Integrative and Functional Nutrition, Saybrook University, Pasadena, CA 91103, USA
| | - Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham University, Wrexham LL11 2AW, UK
| | - Bruce H R Wolffenbuttel
- University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
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2
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Shah SC, Boeder S, Piazuelo MB, Li D. The Stomach Looks Suspicious, But Is It Pernicious? Gastroenterology 2023; 165:1342-1351. [PMID: 37640254 PMCID: PMC11058005 DOI: 10.1053/j.gastro.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Shailja C Shah
- Gastroenterology Section, Jennifer Moreno Department of Veterans Affairs Medical Center, La Jolla, California; Division of Gastroenterology, University of California, San Diego, La Jolla, California.
| | - Schafer Boeder
- Division of Endocrinology and Metabolism, University of California, San Diego, La Jolla, California
| | - M Blanca Piazuelo
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan Li
- Department of Gastroenterology, Kaiser Permanente Northern California, Santa Clara, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
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3
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Romero KN, Patel F, Rai O, Quan A, Reddy P. A Case of Pernicious Anemia Presenting With Severe Hemolysis. Cureus 2023; 15:e50534. [PMID: 38226075 PMCID: PMC10788660 DOI: 10.7759/cureus.50534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/14/2023] [Indexed: 01/17/2024] Open
Abstract
Vitamin B12 deficiency is a well-known and overall common disease. While the etiology of vitamin B12 deficiency varies from post-surgical changes to inadequate dietary consumption, pernicious anemia should be considered as it is a common cause. Pernicious anemia is an autoimmune atrophic gastritis impairing the absorption of vitamin B12. Manifestations include neurological changes, macrocytic anemia, glossitis, and nail changes. Hemolytic anemia is an unusual complication of vitamin B12 deficiency and an even more unusual initial presentation. This case identifies a patient with previously undiagnosed pernicious anemia with severe vitamin B12 deficiency compounded by hemolytic anemia as the presenting symptom. Overall, this case highlights the importance of considering vitamin B12 deficiency-related hemolytic anemia and the need for further research into the causes and pathophysiology of vitamin B12-induced hemolysis due to its potential for fatal outcomes despite being easily treatable with cost-effective methods to treat.
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Affiliation(s)
- Kaitlyn N Romero
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Falguni Patel
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Oshin Rai
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Austin Quan
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Pramod Reddy
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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4
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Ghammad W, Sarthou A, Dutkiewicz M, Vedie B, Neveux N, Le Guillou É, Soret L, Auditeau C, Dragon-Durey MA, Darnige L. [ Pernicious anemia with false normal vitamin B12 levels caused by intrinsic factor antibodies interference: a case report]. Ann Biol Clin (Paris) 2023; 0:abc.2023.1834. [PMID: 37987415 DOI: 10.1684/abc.2023.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
We present a case of a 48-year-old woman with a fortuitous discovery of macrocytic anemia and thrombocytopenia. Serum folate and vitamin B12 levels were normal. However, due to the presence of indirect signs of cobalamin deficiency, such as elevated homocysteine and methylmalonic acid, and signs of dyserythropoiesis on the bone marrow aspirate, pernicious anemia was suspected. Vitamin B12 dosage was repeated finding fluctuating but always normal results. Anti-intrinsic factor antibodies were present at a very high level, explaining the fluctuations and the interference found on the assay using competitive binding chemiluminescence (CBLA). Serum vitamin B12 dosage by electrochemiluminescence, a method described as not interfering with intrinsic factor antibodies, showed a collapsed vitamin B12 level. Measurement of vitamin B12 with CBLA after adsorption of immunoglobulins in the sample using protein G SepharoseTM, confirmed the interference of the cobalamin assay with autoantibodies. This case illustrates the difficulties regarding the analysis and standardization of the vitamin B12 assay for the diagnosis of pernicious anemia.
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Affiliation(s)
- Wiame Ghammad
- Service d'Hématologie biologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Aurélie Sarthou
- Service d'Hématologie biologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Marion Dutkiewicz
- Service d'Hématologie biologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Benoit Vedie
- Service de Biochimie, Hôpital Européen Georges-Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Nathalie Neveux
- Service de Biochimie, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Édouard Le Guillou
- Service de Biochimie, Hôpital Necker, 149 Rue de Sèvres, 75015 Paris, France
| | - Lou Soret
- Service d'Hématologie biologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Claire Auditeau
- Service d'Hématologie biologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Marie-Agnès Dragon-Durey
- Service d'Immunologie biologique, Hôpital Européen Georges-Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Luc Darnige
- Service d'Hématologie biologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
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5
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Brochado AI, Marques Dias J, Azevedo Ferreira M, Grilo A, Gonçalves A. Pernicious Anemia With Spuriously Normal B12 Levels. Cureus 2023; 15:e48937. [PMID: 38106734 PMCID: PMC10725556 DOI: 10.7759/cureus.48937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
We present a 29-year-old man admitted to our hospital with fatigue for two months of duration and recent palpitations, lightheadedness, blurred vision and nausea. Workup showed pancytopenia with severe macrocytic anemia, laboratory and blood smear features of hemolysis, low reticulocyte percentage and a negative direct Coombs test. B12 and folate levels were normal. As bone marrow aspirate was suggestive of megaloblastic anemia and upper endoscopy showed atrophic gastritis, we ordered homocysteine (elevated) and intrinsic factor (IF) antibodies (positive). The workup led to the diagnosis of pernicious anemia with spuriously normal B12 levels. Replacement therapy allowed a rapid recovery. We highlight that the presence of IF antibodies can interfere with the competitive binding assays commonly used to measure B12 levels.
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Affiliation(s)
| | | | | | - Ana Grilo
- Internal Medicine Department, Hospital Beatriz Ângelo, Loures, PRT
| | - Ana Gonçalves
- Intensive Care Unit Department, Hospital Beatriz Ângelo, Loures, PRT
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Khaliq L, Kabir KF, Pyai K, Hadid T, Collins-Hamel B. A Simple Vitamin Deficiency With Life-Threatening Complications: A Case of B12 Deficiency and Hyperhomocysteinemia-Induced Thrombosis. Cureus 2023; 15:e42908. [PMID: 37664295 PMCID: PMC10474896 DOI: 10.7759/cureus.42908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
While macrocytic anemia is common in vitamin B12 deficiency, rarely, pancytopenia and hemolytic anemia can occur. Homocysteine levels are elevated in severe B12 deficiency, and this is linked to thrombus formation with potentially life-threatening complications. We present a patient with severe vitamin B12 deficiency complicated by hyperhomocysteinemia and obstructive shock from pulmonary embolism. A 56-year-old male with no medical history presented to the hospital with altered mentation. The patient's family stated he was experiencing bilateral paresthesias of his lower extremities, progressive depression, anxiety, and insomnia. Initial vitals were blood pressure of 76/36, heart rate of 70 beats per minute, respiratory rate of 14, and temperature of 36.3 degrees Celsius. He was intubated due to severe encephalopathy. Relevant labs indicated severe macrocytic anemia, thrombocytopenia, decreased B12 levels, elevated methylmalonic acid, and elevated homocysteine. Imaging demonstrated a right common femoral vein thrombosis and subsegmental pulmonary emboli. Peripheral blood smear revealed schistocytes, anisopoikilocytosis, and decreased platelet count. The patient required fluid resuscitation, antibiotics, and multiple blood products. Vitamin B12 was administered intramuscularly, which improved the anemia. Esophagogastroduodenoscopy (EGD) demonstrated gastritis. Gastric and duodenal biopsies were negative for Helicobacter pylori and celiac disease. He was negative for intrinsic factor (IF) antibodies but had elevated gastrin levels. An intravenous unfractionated heparin infusion was started when the platelet count was above 50000. The patient was extubated after seven days. Heparin was transitioned to apixaban and an inferior vena cava (IVC) filter was placed. Hyperhomocysteinemia is a known pro-thrombotic factor that can lead to the development of venous thromboembolism. B12 malabsorption can stem from inflammatory bowel disease, celiac disease, gastritis, pancreatic insufficiency, gastrectomy, gastric bypass surgery, or antibodies to IF. While this case showed gastritis and negative IF antibodies, gastrin levels were elevated, indicating a mixed picture. This highlights the challenge of definitively diagnosing pernicious anemia as the cause of vitamin B12 deficiency. Vitamin B12 deficiency may lead to critical illness in which thromboembolism develops secondary to hyperhomocysteinemia.
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Affiliation(s)
- Laiba Khaliq
- Internal Medicine, Ascension Macomb Oakland, Warren, USA
- Internal Medicine, Michigan State University College of Osteopathic Medicine, Warren, USA
| | - Kaiser F Kabir
- Internal Medicine, Ascension Macomb Oakland, Warren, USA
- Internal Medicine, Michigan State University College of Osteopathic Medicine, Warren, USA
| | - Khin Pyai
- Internal Medicine, Ascension Macomb Oakland, Warren, USA
| | - Tarik Hadid
- Oncology, Ascension St. John Hospital and Medical Centre, Detroit, USA
| | - Benjamin Collins-Hamel
- Internal Medicine, Ascension Macomb Oakland, Warren, USA
- Internal Medicine, Michigan State University College of Osteopathic Medicine, Warren, USA
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7
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Ibraheem A, Nashwan AJ, Yassin MA. Elderly Patient With Hematological and Neurological Manifestations of Undetermined Origin: A Diagnostic Dilemma of Pernicious Anemia. Cureus 2023; 15:e43045. [PMID: 37680425 PMCID: PMC10480558 DOI: 10.7759/cureus.43045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 09/09/2023] Open
Abstract
Pernicious anemia (PA) is a chronic inflammatory destructive disease of parietal cells of predominantly the gastric fundus. It leads to vitamin B12 (cobalamin) deficiency secondary to a deficiency of intrinsic factors. Despite the medical advances nowadays, diagnosing PA can be challenging. This report highlights a neglected case of PA with ongoing subacute combined degeneration of the cord (SCDS) in an elderly patient. An 86-year-old lady with multiple comorbidities was referred to the hematology outpatient clinic for refractory anemia for the last two months. At first, her general practitioner (GP) treated her as a case of anemia of chronic disease but without improvement. Her initial clinical assessment revealed hematological and neurological manifestations of undetermined origin, including global weakness, hypertonia, and hyperreflexia with sensory deficits, especially in the lower limbs. On investigation, the hemoglobin level was 9 g/dL with high indirect bilirubinemia and lactate dehydrogenase (LDH). Despite the normal mean corpuscular volume (MCV) and peripheral blood smear, positive anti-intrinsic factor and parietal cell antibodies tests were subsequently reported, suggesting the diagnosis of PA. As a result, she was commenced on lifelong parenteral cobalamin replacement therapy. On follow-up visits of three months, she illustrated a clinical recovery in fatigability and paranesthesia. As expected, the laboratory parameters revealed a rise in hemoglobin level (11 g/dL) and serum vitamin B12 (418 pg/mL). However, she remained bedridden with spastic limbs. Clinicians should have a high index of suspicion since PA is a rare disease with variable clinical presentations. The optimal management approach is by a multidisciplinary care team of internists, neurologists, gastroenterologists, and hematologists.
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Affiliation(s)
- Anas Ibraheem
- Internal Medicine, Imamein Kadhimein Medical City, Baghdad, IRQ
- Internal Medicine, Clinical Hematology, Al Karama Teaching Hospital, Baghdad, IRQ
| | | | - Mohamed A Yassin
- Hematology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, QAT
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8
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Fraile L, Sopena A, Chávez CE, Font-Font M, Esquerda A. Autoantibodies to intrinsic factor can jeopardize pernicious anemia diagnosis: a case report. EJIFCC 2023; 34:181-187. [PMID: 37455840 PMCID: PMC10349311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Vitamin B12 deficiency may cause neurological and hematological alterations. Its assessment should be easy considering that the access to its measurement is available in majority of the clinical laboratories. The presence of technical interference when measuring vitamin B12 can lead to an erroneous or a more difficult diagnosis of conditions as pernicious anemia. We report a case in which an interference in the evaluation of vitamin B12 concentration led to the realization of invasive tests and almost a misdiagnosis of a patient who actually had pernicious anemia. Professionals need to be aware of these interferences when we assess outcomes.
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Affiliation(s)
- Lucía Fraile
- Corresponding author: Lucía Fraile García Servicio de Análisis Clínicos Hospital Universitari Arnau de Vilanova Avenida Rovira Roure 80 25198. Lleida Spain Phone: +34 691754564 E-mail:
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9
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Arram N, Riyaz R, khatroth S, Shrestha AB. A case report on autoimmune polyglandular syndrome type 2 with pernicious anemia. Clin Case Rep 2023; 11:e7413. [PMID: 37305884 PMCID: PMC10250687 DOI: 10.1002/ccr3.7413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 04/09/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023] Open
Abstract
Autoimmune polyglandular syndrome type 2 (APS II) is a rare autoimmune disease that affects many endocrine glands. We present a case of a 32-year-old man with Addison's disease, autoimmune thyroiditis, and pernicious anemia. Multi-line and timely management are crucial for each association.
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Affiliation(s)
- Niharikha Arram
- Apollo Institute of Medical Sciences and ResearchHyderabadIndia
| | - Romana Riyaz
- Shadan Institute of Medical Sciences and ResearchHyderabadIndia
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10
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Alzarkali O, Lee JH, Bower K. Pernicious Anemia Presenting as a Mimicker of Thrombotic Thrombocytopenic Purpura. Cureus 2023; 15:e39080. [PMID: 37332426 PMCID: PMC10269394 DOI: 10.7759/cureus.39080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/20/2023] Open
Abstract
A 52-year-old woman with no significant past medical history presented to the emergency room (ER) with nonspecific systemic symptoms, including fatigue, dyspnea on exertion, easy bruising, and palpitations. She was found to have significant pancytopenia. Hemolytic anemia, thrombocytopenia, and elevated PLASMIC score (6, High risk; PLASMIC = Platelet count; combined hemoLysis variable; absence of Active cancer; absence of Stem-cell or solid-organ transplant; MCV; INR; Creatinine) score at the time of presentation led to a concern for thrombotic thrombocytopenic purpura (TTP). Therapeutic plasma exchange (TPE) was deferred pending additional investigation. Workup revealed the true diagnosis of severe B12 deficiency, which would not have benefited from TPE and instead would have placed the patient at risk for harm, making the decision to defer treatment the correct and judicious approach. This is a case where anchoring on lab results may result in reaching the incorrect diagnosis. This case reminds clinicians of the importance of creating a broad differential and ensuring thorough history-taking is done for all patients.
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Affiliation(s)
- Omar Alzarkali
- Internal Medicine, HCA Florida Blake Hospital, Bradenton, USA
| | - Jane H Lee
- Internal Medicine, HCA Florida Blake Hospital, Bradenton, USA
| | - Kathryn Bower
- Hematology and Medical Oncology, HCA Florida Blake Hospital, Bradenton, USA
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Yocum AD, Patel M, Palocko B, Simon EL. Primary Neurologic Symptoms: Have You Considered Pernicious Anemia? J Emerg Med 2023; 64:217-219. [PMID: 36739174 DOI: 10.1016/j.jemermed.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/06/2022] [Accepted: 10/21/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. CASE REPORT A 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.
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Affiliation(s)
- Andrew D Yocum
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Mili Patel
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Bradley Palocko
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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Chen C, Yang Y, Li P, Hu H. Incidence of Gastric Neoplasms Arising from Autoimmune Metaplastic Atrophic Gastritis: A Systematic Review and Case Reports. J Clin Med 2023; 12. [PMID: 36769710 DOI: 10.3390/jcm12031062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/31/2023] Open
Abstract
Autoimmune metaplastic atrophic gastritis (AMAG) is associated with an increased risk of gastric neoplasms. This study aimed to systematically analyze the incidence rate of gastric cancer (GC), low-grade dysplasia (LGD) and type-1 gastric neuroendocrine tumor (gNETs) development in AMAG adults. Studies on AMAG patients reporting the incidence of gastric neoplasms was identified through a systematic search in PUBMED and EMBASE. Study quality was assessed using the Joanna Briggs Institute quality assessment tool. Incidence rates of GC, LGD and type-1 gNETs were examined by meta-analysis. Thirteen studies met eligibility criteria. Incidence rate of gastric cancer calculated from the pooled data was 0.14% per person-year in both single-center studies and national registration studies. Meta-analysis showed a relative risk of 11.05 (95% CI: 6.39-19.11) for gastric cancer development in AMAG patients. The calculated pooled gastric LGD and type-1 gNETs incidence rates were 0.52% and 0.83% per person-year, respectively. As for experience from our center, we presented three distinctive cases of gastric neoplasm arising from the background of AMAG. This study underscores the potential for malignant transformation of precancerous lesions and reiterates the importance of careful esophagogastroduodenoscopy screening.
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Cotton M, McCaddon A. Examining the Diagnosis and Treatment Experiences of People Living With Autoimmune Gastritis and Pernicious Anemia. J Patient Exp 2023; 10:23743735231151767. [PMID: 36698620 PMCID: PMC9869222 DOI: 10.1177/23743735231151767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
There is limited research evaluating the diagnosis and treatment of patients with autoimmune gastritis (AIG) and pernicious anemia (PA). We used a 2-phase data collection process to examine the literature and individual patient accounts. Phase one comprised a systematically conducted literature review focusing on diagnosis and treatment, relationships with healthcare practitioners and health-related quality of life (HRQOL). Phase two involved analysis of individual accounts via posts in online patient forums. We identified 6 main themes: the diagnosis journey, seeking treatment, patient-provider relationships, HRQOL, patient disempowerment, and the "expert patient." Our findings confirm significant knowledge gaps concerning AIG/PA across the healthcare community. These have a cascading effect starting with delays in diagnosis and poor treatment protocols and often lead to complete withdrawal from care seeking. The establishment of standard consensus guidelines and improved clinical awareness should be urgently addressed. Interventions that better help patients understand their illness are also needed to improve psychological health. Without these changes disengagement from health systems, and poor health outcomes, will continue for this population group.
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Affiliation(s)
- Martine Cotton
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham Glyndwr University, Wrexham, UK,Martine Cotton, School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia.
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Muacevic A, Adler JR, Ghallab M, Abdelwahed M, Ali A, Ibrahim B, Kimball E. Pernicious Anemia and Vitamin B12 Deficiency Presenting As Pseudothrombotic Microangiopathy and Developing Secondary Thrombocytopenia After Treatment: A Case Report. Cureus 2022; 14:e32095. [PMID: 36601163 PMCID: PMC9804028 DOI: 10.7759/cureus.32095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
Pernicious anemia (PA) is an autoimmune disease secondary to chronic atrophic gastritis leading to vitamin B12 deficiency. Rarely, some patients may develop advanced hematological complications that mimic those of thrombotic thrombocytopenic purpura (TTP). Differentiating these conditions is crucial because they require different management. We present a case of a 68-year-old male who presented with generalized weakness, fatigue, and shortness of breath. This patient had anemia, thrombocytopenia, and a markedly deficient serum level of vitamin B12. The symptoms initially mimicked those associated with TTP, but the activity of ADAMTS 13 was normal. A diagnosis of pseudo-TTP has been made due to vitamin B12 deficiency resulting from PA with reactive thrombocytosis. Ultimately, vitamin B12 deficiency pseudo-TTP should be considered a differential diagnosis for therapy refractory TTP because of its different management strategies ranging from parenteral Vitamin B12 in PA patients with highly favorable outcomes to more advanced treatment with less favorable outcomes in TTP patients.
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Esposito G, Dottori L, Pivetta G, Ligato I, Dilaghi E, Lahner E. Pernicious Anemia: The Hematological Presentation of a Multifaceted Disorder Caused by Cobalamin Deficiency. Nutrients 2022; 14:nu14081672. [PMID: 35458234 PMCID: PMC9030741 DOI: 10.3390/nu14081672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Pernicious anemia is still a neglected disorder in many medical contexts and is underdiagnosed in many patients. Pernicious anemia is linked to but different from autoimmune gastritis. Pernicious anemia occurs in a later stage of autoimmune atrophic gastritis when gastric intrinsic factor deficiency and consequent vitamin B12 deficiency may occur. The multifaceted nature of pernicious anemia is related to the important role of cobalamin, which, when deficient, may lead to several dysfunctions, and thus, the proteiform clinical presentations of pernicious anemia. Indeed, pernicious anemia may lead to potentially serious long-term complications related to micronutrient deficiencies and their consequences and the development of gastric cancer and type 1 gastric neuroendocrine tumors. When not recognized in a timely manner or when pernicious anemia is diagnosed with delay, these complications may be potentially life-threatening and sometimes irreversible. The current review aimed to focus on epidemiology, pathogenesis, and clinical presentations of pernicious anemia in an attempt to look beyond borders of medical specialties. It aimed to focus on micronutrient deficiencies besides the well-known vitamin B12 deficiency, the diagnostic approach for pernicious anemia, its long-term complications and optimal clinical management, and endoscopic surveillance of patients with pernicious anemia.
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16
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Aon M, Taha S, Mahfouz K, Ibrahim MM, Aoun AH. Vitamin B12 (Cobalamin) Deficiency in Overt and Subclinical Primary Hypothyroidism. Clin Med Insights Endocrinol Diabetes 2022; 15:11795514221086634. [PMID: 35340751 PMCID: PMC8943463 DOI: 10.1177/11795514221086634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background: B12 (cobalamin) deficiency has been reported in hypothyroid patients with
variable prevalence rates thus routine screening of hypothyroid patients was
recommended by some and discouraged by others. We aimed to assess the
prevalence of B12 deficiency among hypothyroid patients and to evaluate for
pernicious anemia and celiac disease as etiologies. Methods: A total 133 patients were included. Thyroid hormones and thyroid peroxidase
(TPO) autoantibodies were measured. Serum B12 was measured and if deficient,
intrinsic factor antibodies (IFAB) and tissue transglutaminase (tTG)
antibodies were evaluated. Results: Our study included 45 patients with overt hypothyroidism (OH), 48 patients
with subclinical hypothyroidism (SCH), and 40 patients as controls. Mean age
was 34.3 years and 82% were females. TPO antibodies were positive in 73.5%
of OH and 51.1% of SCH patients. B12 deficiency was detected in 33.3%,
47.9%, and 37.5% of OH, SCH, and controls, respectively with no significant
difference (P = .334). Borderline-to-low B12 level was more
prevalent in the OH and the SCH groups compared to controls (68.9%, 85.4%,
and 57.5%, respectively; P = .014). Among B12-deficient
hypothyroid patients, 7.5% had positive IFAB and 13.3% had positive tTG
antibodies. We did not find a significant association of TPO positivity and
B12 deficiency (OR, 0.69; 95% CI 0.3-1.57; P = .147). Conclusion: We did not find a higher prevalence of B12 deficiency among hypothyroid
patients nor an association with TPO positivity. Borderline B12 levels were
more prevalent among hypothyroid patients.
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Affiliation(s)
- Mohamed Aon
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Sherif Taha
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt.,Department of Internal Medicine, Jahra Hospital, Jahra, Kuwait
| | - Khaled Mahfouz
- Department of Internal Medicine, Jahra Hospital, Jahra, Kuwait
| | - Mohamed M Ibrahim
- Department of Clinical Pharmacology, Jahra Hospital, Jahra, Kuwait.,Department of Clinical Pharmacology, 6th October University, 6th October city, Egypt
| | - Ahmed H Aoun
- Department of Pediatrics, Faculty of Medicine, Cairo University, Giza, Egypt
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17
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Matsushima S, Kato K, Yoshimi A, Yoshiura KI, Tsuchida M. Pernicious anemia associated with Kabuki syndrome. Pediatr Int 2022; 64:e14960. [PMID: 35092638 DOI: 10.1111/ped.14960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 07/21/2021] [Accepted: 08/17/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Satoru Matsushima
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - Keisuke Kato
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - Ai Yoshimi
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - Koh-Ichiro Yoshiura
- Department of Human Genetics, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Masahiro Tsuchida
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
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18
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Selhub J, Miller JW, Troen AM, Mason JB, Jacques PF. Perspective: The High-Folate-Low-Vitamin B-12 Interaction Is a Novel Cause of Vitamin B-12 Depletion with a Specific Etiology-A Hypothesis. Adv Nutr 2021; 13:16-33. [PMID: 34634124 PMCID: PMC8803489 DOI: 10.1093/advances/nmab106] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/12/2022] Open
Abstract
Vitamin B-12 is a water-soluble vitamin that plays important roles in intermediary metabolism. Vitamin B-12 deficiency has many identifiable causes, including autoimmune and other gastrointestinal malabsorption disorders, dietary deficiency, and congenital defects in genes that are involved in vitamin B-12 trafficking and functions. Another putative cause of vitamin B-12 deficiency is the high-folate-low vitamin B-12 interaction, first suspected as the cause for observed relapse and exacerbation of the neurological symptoms in patients with pernicious anemia who were prescribed high oral doses of folic acid. We propose that this interaction is real and represents a novel cause of vitamin B-12 depletion with specific etiology. We hypothesize that excessive intake of folic acid depletes serum holotranscobalamin (holoTC), thereby decreasing active vitamin B-12 in the circulation and limiting its availability for tissues. This effect is specific for holoTC and does not affect holohaptocorrin, the inert form of serum vitamin B-12. Depletion of holoTC by folic acid in individuals with already low vitamin B-12 status further compromises the availability of vitamin B-12 coenzymes to their respective enzymes, and consequently a more pronounced state of biochemical deficiency. This hypothesis is drawn from evidence of observational and intervention studies of vitamin B-12-deficient patients and epidemiological cohorts. The evidence also suggests that, in a depleted state, vitamin B-12 is diverted to the hematopoietic system or the kidney. This most likely reflects a selective response of tissues expressing folate receptors with high affinity for unmetabolized folic acid (UMFA; e.g., hematopoietic progenitors and renal tubules) compared with those tissues (e.g., liver) that only express the reduced folate carrier, which is universally expressed but has poor affinity for UMFA. The biochemical and physiological mechanisms underlying this interaction require elucidation to clarify its potential public health significance.
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Affiliation(s)
| | | | - Aron M Troen
- School of Nutritional Sciences and Institute of Biochemistry Food Science and Nutrition, The Robert H Smith Faculty of Agriculture Food and Environment, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joel B Mason
- Tufts–USDA Human Nutrition Research Center on Aging, Boston, MA, USA
| | - Paul F Jacques
- Tufts–USDA Human Nutrition Research Center on Aging, Boston, MA, USA
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19
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Odisho T, Shi D, Aburashed A. Successful endoscopic resection of an unusually enlarged and pedunculated type I gastric carcinoid tumour. BMJ Case Rep 2021; 14:e244292. [PMID: 34413045 PMCID: PMC8378368 DOI: 10.1136/bcr-2021-244292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 11/04/2022] Open
Abstract
Three distinct gastric carcinoid (GC) tumour types have been described based on differing biological behaviour and prognoses. Type I GC tumours account for the vast majority (70%-80%), are associated with chronic atrophic gastritis and have a low metastatic potential. Type II carcinoid tumours are the least common (5%-10%), are related to Zollinger-Ellison syndrome and occur in relation to multiple neoplasia type I. Sporadic type III tumours (15%-25%) are the most aggressive type, are unrelated to gastrin over secretion and carry the worst prognosis. In this case report, we present a patient with longstanding gastroesophageal reflux disease (GERD) who presented with epigastric abdominal pain and tarry stools and was found to have a large gastric polyp on endoscopy. Despite current literature recommending surgical resection for larger GC tumours, endoscopic resection was successfully used to excise the tumour with pathology demonstrating complete resection with negative margins.
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Affiliation(s)
- Tanya Odisho
- Department of Surgery, Detroit Medical Center, Detroit, Michigan, USA
| | - Dongping Shi
- Department of Pathology, Detroit Medical Center, Detroit, Michigan, USA
| | - Ahmad Aburashed
- Department of Gastroenterology, Detroit Medical Center, Detroit, Michigan, USA
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20
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Wilcox NS, Tapé C, Cordisco AJ, Than MT, Zuroff L, Dobkin J, Massa RC, Lytle AG, Bagg A, Min H, Glaser LJ, Kosseim LM. Anemia in a young Guinean male. Clin Case Rep 2021; 9:e04593. [PMID: 34401166 PMCID: PMC8346596 DOI: 10.1002/ccr3.4593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/13/2021] [Accepted: 06/28/2021] [Indexed: 11/12/2022] Open
Abstract
The etiology of anemia in adults is often multifactorial. This case highlights an uncommon combination of causes of anemia and the importance of a diagnostic workup guided by a patient's unique history, risk factors, and laboratory findings.
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Affiliation(s)
- Nicholas S. Wilcox
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Chantal Tapé
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Anthony J. Cordisco
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Minh T. Than
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Leah Zuroff
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jane Dobkin
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Ryan C. Massa
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Andrew G. Lytle
- Department of PathologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Adam Bagg
- Department of PathologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Htun Min
- Department of PathologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Laurel J. Glaser
- Department of PathologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Laura M. Kosseim
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
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21
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Shimozono K. [An adult case of Hashimoto's thyroiditis accompanying pernicious anemia and subacute combined degeneration]. Rinsho Shinkeigaku 2021; 61:461-465. [PMID: 34148933 DOI: 10.5692/clinicalneurol.cn-001551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 66-year old man presented to our hospital due to gait disturbance. He was unable to stand or walk without assistance. Laboratory tests revealed macrocytic anemia and an extremely low serum vitamin B12 level. MRI showed high- intensity signals in the posterior and lateral column of the cervical and thoracic region of the spinal cord in T2 weighted image. Other significant laboratory results were an increased and/or positive anti-thyroid peroxidase antibody, anti-gastric parietal cell antibody and anti-intrinsic factor antibody. He was diagnosed with a combination of Hashimoto's thyroiditis, pernicious anemia and subacute combined degeneration of the spinal cord (SCD). The patient's condition was autoimmune polyglandular syndrome type3B. The association of thyroid and gastric autoimmune disorders is a unique syndrome that tend to be complicated by vitamin B12 deficiency.
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22
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Bapatla A, Syed A, Mohammed AFS, Jones CV, Ismail R. Type I Gastric Neuroendocrine Tumor Presenting as Acute Upper Gastrointestinal Bleed. Cureus 2021; 13:e15343. [PMID: 34094786 PMCID: PMC8172005 DOI: 10.7759/cureus.15343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Gastric neuroendocrine tumors (GNETs) are rare and subdivided into type I, type II, and type III. Types I and II are gastrin-dependent and are usually benign, whereas type III is gastrin-independent and more aggressive. Type I accounts for 70-80% of all GNETs. Most of them are asymptomatic and incidentally detected on endoscopy. It can sometimes present with iron and B12 deficiency, dyspepsia, and less commonly with an upper GI bleed. We present a case of type I GNET who came to the hospital with melena and esophagogastroduodenoscopy (EGD) showing a 3-cm bleeding polyp and histopathology revealing a well-differentiated neuroendocrine tumor with angioinvasion.
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Affiliation(s)
- Anusha Bapatla
- Internal Medicine, Wayne State University, Detroit Medical Center (DMC) Sinai Grace Hospital, Detroit, USA
| | - Ameena Syed
- Internal Medicine, Wayne State University, Detroit Medical Center (DMC) Sinai Grace Hospital, Detroit, USA
| | - Abu Fazal Shaik Mohammed
- Internal Medicine, Wayne State University, Detroit Medical Center (DMC) Sinai Grace Hospital, Detroit, USA
| | - Cortney V Jones
- Hematology and Oncology, Wayne State University, Detroit Medical Center (DMC) Sinai Grace Hospital, Detroit, USA
| | - Rana Ismail
- Internal Medicine, Wayne State University, Detroit Medical Center (DMC) Sinai Grace Hospital, Detroit, USA
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23
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Riaz A, Khan S, Miret R, Bejarano P, Ur Rahman A. Autoimmune Hepatitis With Concomitant Pernicious Anemia: A Rare Association. Cureus 2021; 13:e15045. [PMID: 34150396 PMCID: PMC8203103 DOI: 10.7759/cureus.15045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The co-occurrence of autoimmune hepatitis (AIH) and pernicious anemia (PA) is extremely rare. We present a case of a 70-year-old woman with AIH who presented for the evaluation of poor appetite and weight loss. Laboratory studies were significant for microcytic anemia, B12, and iron deficiency. Esophagogastroduodenoscopy showed diffuse gastric mucosal atrophy, and the pathology from the body of the stomach showed chronic gastritis. Additional testing was positive for parietal cell antibody and intrinsic factor blocking antibody, confirming the diagnosis of PA. To the best of our knowledge, there is only one documented case of AIH associated with PA.
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Affiliation(s)
- Amir Riaz
- Internal Medicine, Cleveland Clinic Florida, Weston, USA
| | - Sikandar Khan
- Internal Medicine, Cleveland Clinic Florida, Weston, USA
| | - Rafael Miret
- Internal Medicine, Cleveland Clinic Florida, Weston, USA
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24
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Abstract
Pernicious anemia (PA) is the most common cause of vitamin B12 (cobalamin) deficiency anemia in the world. It is an autoimmune disease, comprising of salient features of autoimmune chronic atrophic gastritis (CAG) and cobalamin deficiency (CD). Although the anemia was first described as pernicious, it may well be controlled with vitamin B12 replacement. The onset and progression of PA is often insidious. Alternatively, patients may have no anemic symptoms since they become acclimatized to the subtle nature of the disease. Oftentimes, there is a possibility that the underlying disease may be missed unless a full blood count (FBC) is investigated, leading to hindrance in the treatment journey. Diagnostic challenges remain tangible for many practicing clinicians, since there is lack of reliable cobalamin assays to diagnose CD as well as clinical mimics, which simulate many other hematological conditions, such as myelodysplastic syndrome, acute leukemia, sideroblastic anemias, bone marrow failure states, thrombotic microangiopathy, and thromboembolism. Moreover, prompt recognition of the symptoms of CD is also vital, because some neurologic sequalae may become irreversible despite replenishing cobalamin. Herein, we discuss a literature review on the pathophysiology, challenging clinical presentations and diagnostic difficulties of PA. Since the cobalamin replacement therapy for PA is straightforward, it will not be discussed in this review.
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Affiliation(s)
- Thura Win Htut
- Department of Hematology, Aberdeen Royal Infirmary Hospital, The University of Aberdeen, NHS Grampian, Scotland, UK
| | - Kyaw Zin Thein
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Thein Hlaing Oo
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, USA
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25
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Seage CH, Semedo L. How Do Patients Receiving Prescribed B 12 Injections for the Treatment of PA Perceive Changes in Treatment During the COVID-19 Pandemic? A UK-Based Survey Study. J Patient Exp 2021; 8:2374373521998842. [PMID: 34179404 PMCID: PMC8205392 DOI: 10.1177/2374373521998842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pernicious anemia (PA) is a chronic condition that is usually treated using B12 injections. Due to the pandemic, many patients were prescribed an alternative oral B12 treatment. There is limited evidence that this is effective at managing symptoms of PA. The aim of this study was to document treatment changes across the United Kingdom and the impact on patient experience. An online survey explored how the treatment of PA has been managed during the early stages of the pandemic; responses were analyzed for a subsample of participants receiving prescribed B12 injections and where changes in treatment applied (n = 329) using content analysis. The most common reported change was the suspension of injections, with oral B12 being offered as an alternative treatment. Patients were concerned about the long-term impact that changes would have on their condition management, and many stated that they were dissatisfied with the level of care received. Those who were supported by health care providers to continue their usual treatment reported experiencing improved health and well-being. This study highlights the major impact of treatment changes on patient health outcomes and the need to further support health care professionals with PA management during and beyond the pandemic.
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Affiliation(s)
- Catherine Heidi Seage
- Department of Applied Psychology, Cardiff Metropolitan University, Cardiff School of Sport and Health Sciences, Cardiff, United Kingdom
| | - Lenira Semedo
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
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Thota V, Paravathaneni M, Bedi V, Branham M, Thirumaran R. Rapid Development of Pernicious Anemia Unmasking Underlying Gastric Adenocarcinoma. Cureus 2021; 13:e13630. [PMID: 33816029 PMCID: PMC8011359 DOI: 10.7759/cureus.13630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Gastric cancer is one of the most common malignancies, often detected at later stages as patients remain asymptomatic until later stages. Pernicious anemia (PA), a well-known cause of vitamin B12 deficiency, is a classic risk factor for gastric cancer. Patients with PA usually present with megaloblastic anemia and peripheral neuropathy; however, they can also present with nonspecific symptoms. We describe below the case of a 56-year-old male who presented with symptoms of nausea, vomiting, and fatigue. Initial lab work revealed severe B12 deficiency, pancytopenia, and intramedullary hemolysis warranting endoscopy that revealed a gastric fundus mass significant for adenocarcinoma on biopsy.
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Affiliation(s)
- Vihitha Thota
- Internal Medicine, Mercy Catholic Medical Center, Darby, USA
| | | | - Verushka Bedi
- Internal Medicine, Mercy Catholic Medical Center, Darby, USA
| | - Michael Branham
- Internal Medicine, Drexel University College of Medicine, Philadelphia, USA
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27
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Das S, Dubey S, Pandit A, Ray BK. Myeloradiculoneuropathy due to vitamin B 12 deficiency: an unusual clinical and radiological presentation. BMJ Case Rep 2021; 14:14/1/e239415. [PMID: 33495192 PMCID: PMC7839883 DOI: 10.1136/bcr-2020-239415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
A 42-year-old man from rural India presented with asymmetric progressive paraparesis mimicking compressive dorsal myelopathy, followed by distal upper limb, truncal and neck-flexor weakness, further complicated by acute urinary retention. His sensory deficits were marked by loss of joint position sense (JPS) and graded loss of vibration sense, along with a definite sensory level. Deep tendon jerks were hypo-to-areflexic, plantar was bilaterally extensor. He had become less attentive and occasionally failed to keep track with conversations. A syndromic diagnosis of myeloradiculoneuropathy with cognitive impairments was made. Further tailored investigations revealed vitamin B12 deficiency with positive anti-parietal cell antibody. Diagnosis of subacute combined cord degeneration (SACD) was confirmed. Neuro-imaging revealed intramedullary intensity changes only along lateral aspect of spinal cord instead of characteristic posterior involvement. Following parenteral vitamin B12 supplementation, patient started showing improvement in motor power and subjective sensory symptoms. His bladder symptoms persisted initially, however recovered finally after 6 months.
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Affiliation(s)
- Shambaditya Das
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Souvik Dubey
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Alak Pandit
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
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28
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Carabotti M, Annibale B, Lahner E. Common Pitfalls in the Management of Patients with Micronutrient Deficiency: Keep in Mind the Stomach. Nutrients 2021; 13:nu13010208. [PMID: 33450823 PMCID: PMC7828248 DOI: 10.3390/nu13010208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 12/31/2020] [Accepted: 01/08/2021] [Indexed: 02/05/2023] Open
Abstract
Micronutrient deficiencies are relatively common, in particular iron and cobalamin deficiency, and may potentially lead to life-threatening clinical consequences when not promptly recognized and treated, especially in elderly patients. The stomach plays an important role in the homeostasis of some important hematopoietic micronutrients like iron and cobalamin, and probably in others equally important such as ascorbic acid, calcium, and magnesium. A key role is played by the corpus oxyntic mucosa composed of parietal cells whose main function is gastric acid secretion and intrinsic factor production. Gastric acid secretion is necessary for the digestion and absorption of cobalamin and the absorption of iron, calcium, and probably magnesium, and is also essential for the absorption, secretion, and activation of ascorbic acid. Several pathological conditions such as Helicobacter pylori-related gastritis, corpus atrophic gastritis, as well as antisecretory drugs, and gastric surgery may interfere with the normal functioning of gastric oxyntic mucosa and micronutrients homeostasis. Investigation of the stomach by gastroscopy plus biopsies should always be considered in the management of patients with micronutrient deficiencies. The current review focuses on the physiological and pathophysiological aspects of gastric acid secretion and the role of the stomach in iron, cobalamin, calcium, and magnesium deficiency and ascorbate homeostasis.
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29
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Simankowicz P, Stępniewska J, Różański J, Ciechanowski K. [Cancer or vitamin B12 deficiency? Difficult differential diagnosis in elderly]. Pol Merkur Lekarski 2020; 48:446-448. [PMID: 33387435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
UNLABELLED Vitamin B12 deficiency anaemia in adults is usually caused by Addison- Biermer's disease. The presence of antibodies against gastric parietal cells and intrinsic factor (IF) in blood is typical for the disease. The gastrointestinal malabsorption or a diet poor in vitamin B12 are rarer causes. The disease manifests in hematological, neurological, psychiatric disorders and trophic changes of the tongue and oral mucosa, which leads to weight loss. A CASE REPORT The authors describe a case of a 70-year-old woman with severe vitamin B12 deficiency based on chronic inflammatory lesions of the gastric mucosa caused by Helicobacter pylori infection. The patient had haematological (pancytopenia), neurological (problems with memory, concentration, numbness of the limbs, gait instability) and gastrological disorders (loss of appetite, weight loss). The laboratory and imaging diagnostics were performed. The neoplasmatic background was abandoned and pure vitamin B12 deficiency was diagnosed. All symptoms resolved completely after the supplementation and eradication of Helicobacter pylori. CONCLUSIONS The article demonstrates the problem of many severe, non- specific complications of vitamin B12 deficiency which requires extensive diagnostics and treatment. The similarity of symptoms may suggest a malignant disease especially in elderly patients.
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Affiliation(s)
- Paulina Simankowicz
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Joanna Stępniewska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Jacek Różański
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Kazimierz Ciechanowski
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
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30
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Mejia Buritica L, Zapata Alvarez J, Vergara Quintero L, Villegas Molina JP, Torres Hernandez JD. Autoimmune Hemolytic Anemia After Cyanocobalamin Replacement in a Patient With a Previous Diagnosis of Pernicious Anemia: A Case Report. Cureus 2020; 12:e10797. [PMID: 33163301 PMCID: PMC7641469 DOI: 10.7759/cureus.10797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Pernicious anemia (PA) is associated with other autoimmune diseases, such as hypothyroidism, type 1 diabetes mellitus (DM1), Addison's disease, and vitiligo. The association between PA and autoimmune hemolytic anemia (AIHA) is rare, with less than 30 cases reported in the literature. In this paper, we report a case of a patient with a confirmed diagnosis of PA, who, six months after starting treatment with cyanocobalamin, presented with severe hemolysis with a positive direct antiglobulin test (DAT) for warm antibodies; the patient responded well to glucocorticoid treatment. AIHA in PA patients can be triggered by cyanocobalamin replacement due to the expression of membrane antigens by mature red blood cells entering into the peripheral circulation. This association should be considered because these patients, in addition to cyanocobalamin replacement, will require immunosuppressive treatment, usually with glucocorticoids.
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Abstract
OBJECTIVES Pernicious anemia (PA) is a chronic condition caused by vitamin B12 deficiency. This is a qualitative study using interpretative phenomenological analysis (IPA), which aimed to explore the patients lived experience of diagnosis and treatment. METHODS Eleven semistructured interviews were conducted in PA patients; these covered participants' diagnostic and treatment journeys, the responses of others to their diagnosis, and the role health professionals have played in their medical care. Interviews were analyzed for recurrent themes using IPA. RESULTS Three superordinate themes were identified: "The struggle to achieve a diagnosis," "The significance of a diagnosis," and "Battling for sufficient treatment." Participants were dissatisfied with their medical care due to diagnostic delay, insufficient treatment, and poor relationships with their health professionals. Many experienced, anticipated, and internalized stigma, which led to a reduced quality of life and withdrawal from the medical profession. DISCUSSION Participants' interactions with their health professionals hindered their adaptation to their condition; this affected their psychological and physical well-being. Increased clinician awareness of stigma in the PA population symptoms and effective patient-centered communication is required.
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Affiliation(s)
- Catherine Heidi Seage
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom
| | - Emily Glover
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom
| | - Jenny Mercer
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom
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Abstract
A 2016 plea for revision of the 1 mg/day upper level of folic acid intake prompted us to comprehensively review the 1945-2017 literature on folic acid hazards in subjects with low cyanocobalamin. The concept of folic acid treatment 'masking' the anemia in undiagnosed cyanocobalamin deficiency, thereby delaying the diagnosis of neuropathy, does not account for the dissociation between the deficiency's hematologic and neurologic manifestations. Possible risks of this concept were addressed by 1963-1971 FDA rulings, classifying all folic acid preparations as prescription-only drugs, delivering ≤1 mg daily. The neuropathy in folic acid trials for 'pernicious anemia' is due to the singular use of folic acid-neuropathy improved or disappeared with replacement of folic acid by liver extract or cyanocobalamin. The hypothesis that cognitive impairment in 'subclinical' cyanocobalamin deficiency is folate-mediated is untenable. Of 6 papers specifically investigating this, none could prove that increased cognitive impairment was related to high folate intake. This review fully supports the safety of the 1 mg/day upper level for folic acid intake.
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Affiliation(s)
- Jan D van Gool
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen-Duisburg University, Essen, Germany
| | - Herbert Hirche
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen-Duisburg University, Essen, Germany
| | - Hildegard Lax
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen-Duisburg University, Essen, Germany
| | - Luc De Schaepdrijver
- Department of Nonclinical Safety, Janssen Research and Development, Beerse, Belgium
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Lahner E, Conti L, Cicone F, Capriello S, Cazzato M, Centanni M, Annibale B, Virili C. Thyro-entero-gastric autoimmunity: Pathophysiology and implications for patient management. Best Pract Res Clin Endocrinol Metab 2020; 34:101373. [PMID: 31864909 DOI: 10.1016/j.beem.2019.101373] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The association between autoimmune atrophic gastritis and thyroid disorders has been observed since the early 1960s and the expression "thyrogastric syndrome" was coined to indicate the presence of thyroid autoantibodies or autoimmune thyroid disease in patients with pernicious anemia, a late clinical stage of autoimmune atrophic gastritis. More recently, it was confirmed that autoimmune thyroid disorders, in particular Hashimoto's thyroiditis, may be frequently associated with other organ-specific, immune-mediated disorders, such as autoimmune atrophic gastritis or celiac disease. The association of Hashimoto's thyroiditis with autoimmune atrophic gastritis or celiac disease in adult patients is currently considered part of the polyglandular autoimmune syndromes which include several autoimmune disorders associated with an autoaggressive impairment of endocrine glands. From a clinical point of view, the thyro-entero-gastric autoimmunity may lead to potentially serious consequences like anemia, micronutrients deficiencies, and drugs malabsorption, as well as to an increased risk for malignancies. These alterations may frequently present in an underhand manner, with consequent diagnostic and treatment delays. Many aspects of the association between thyroid, gastric and intestinal autoimmune diseases still await clarification. The present review focuses on the embryological, genetic and pathophysiological aspects of thyro-entero-gastric autoimmunity. In particular, the current diagnostic criteria of autoimmune thyroid disease, autoimmune atrophic gastritis, and celiac disease are reviewed, along with the evidences for their association in poly-autoimmunity syndromes. The benefits of proactive screening of autoimmune thyroid disorders in patients with autoimmune gastritis or enteropathy and viceversa are also discussed.
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Affiliation(s)
- Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Laura Conti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Francesco Cicone
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Silvia Capriello
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
| | - Maria Cazzato
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
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Wu L, Shi B, Zhao M, Sun H, Zhang F, Li J, Huang D, Shi Z. Rare anterior funiculus lesions in subacute combined degeneration of the spinal cord: a case report and literature review. Int J Neurosci 2019; 130:343-347. [PMID: 31675909 DOI: 10.1080/00207454.2019.1688805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Anterior funiculus lesion is uncommon in subacute combined degeneration of the spinal cord with few data available. Aim of the study was to describe a case with the rare manifestation and summarize existing literatures.Methods: We report a case of a 42-year-old woman with anterior and lateral funiculus lesions on cervicothoracic spine magnetic resonance imaging, who presented with unsteady gait, sensory level and weakness of lower limbs. Besides, we reviewed and analyzed literatures about subacute combined degeneration of the spinal cord with anterior funiculus lesions published during the past two decades.Results: The diagnosis of subacute combined degeneration of the spinal cord was considered due to her presence of low serum vitamin B12 levels, pernicious anemia and gastric carcinoid.Conclusion: Physicians should consider subacute combined degeneration of the spinal cord as a possible differential diagnosis when faced with atypical lesions distributed in the anterior funiculus.
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Affiliation(s)
- Lei Wu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Bingxin Shi
- Department of Neurology, Yuquan Hospital, School of Clinical Medicine, Tsinghua University, Beijing, PR China
| | - Mangsuo Zhao
- Department of Neurology, Yuquan Hospital, School of Clinical Medicine, Tsinghua University, Beijing, PR China
| | - Hui Sun
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Fangfang Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Jie Li
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Dehui Huang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Zhen Shi
- Department of Radiology, PLA 148 Hospital, Zibo, Shandong, PR China
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35
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Berry RJ. Lack of historical evidence to support folic acid exacerbation of the neuropathy caused by vitamin B12 deficiency. Am J Clin Nutr 2019; 110:554-561. [PMID: 31187858 PMCID: PMC6785032 DOI: 10.1093/ajcn/nqz089] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/17/2019] [Indexed: 12/22/2022] Open
Abstract
In 1998 a Tolerable Upper Intake Level (UL) for folic acid was established based on case reports from the 1940s suggesting that high-dosage folic acid intake, used to treat patients with pernicious anemia, had the potential to precipitate or speed-up the development of neurological problems. This UL has been employed in the decision-making process used by more than 80 countries to establish programs to fortify staple foods with folic acid to prevent neural tube birth defects. Some have claimed that this UL is flawed and has become an obstacle to the wider adoption of neural tube defect prevention programs and have called for re-evaluation of the scientific validity of this UL. Case reports cannot establish causality, but they can reveal patterns in the timing of the onset and treatment of patients with pernicious anemia. These patterns can be compared with secular trends of usual medical practice for the treatment of pernicious anemia and with the changes in usage of folic acid preparations, including recommended therapeutic dosage and precautions for its usage surrounding the synthesis of folic acid in 1945 and vitamin B12 in 1948. Folic acid package inserts, early editions of hematology textbooks, and international expert reports provide valuable historical information. The recommended therapeutic daily dosage for folic acid of 5-20 mg was unchanged from 1946 through to 1971. The likely cause of the neurological problems encountered is the development of vitamin B12 neuropathy when pernicious anemia was treated with high-dosage folic acid before vitamin B12 was widely available in the early 1950s. Thus, the historical record does not provide compelling evidence that folic acid can potentially cause neurologic complications among those with low vitamin B12 status and lends support for reconsidering the basis for the UL of folic acid.
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Affiliation(s)
- Robert J Berry
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA
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36
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Kesbeh Y, Pakbaz Z. Pernicious anemia: a myelodysplastic syndrome look-alike. J Community Hosp Intern Med Perspect 2019; 9:240-243. [PMID: 31258865 PMCID: PMC6586112 DOI: 10.1080/20009666.2019.1622382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/13/2019] [Indexed: 11/29/2022] Open
Abstract
Severe cytopenias (anemia, thrombocytopenia, neutropenia or any combination of these) are common causes of ER visits and hospital admissions. In adults, the etiology of cytopenias has a broad differential diagnosis including vitamin and mineral deficiencies, autoimmune conditions, infections, bone marrow failure disorders, or malignancies. We present a case of severe anemia and thrombocytopenia who was initially diagnosed with myelodysplastic syndrome (MDS) based on the results of a bone marrow biopsy. However, subsequent workup revealed that she had B12 deficiency secondary to pernicious anemia. This case highlights how performing a bone marrow biopsy without investigating secondary causes of cytopenia and bone marrow dysplasia can lead to a false diagnosis of MDS. Confirmation of the appropriate diagnosis spared the patient emotional trauma and unnecessary treatment with hypomethylating agents.
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Affiliation(s)
- Yazeed Kesbeh
- Hematology, Riverside University Health System Medical Center, Moreno Valley, CA, USA.,Department of Internal Medicine, University of California School of Medicine, Riverside, CA, USA
| | - Zahra Pakbaz
- Hematology, Riverside University Health System Medical Center, Moreno Valley, CA, USA.,Department of Internal Medicine, University of California School of Medicine, Riverside, CA, USA.,Department of Internal Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
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37
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Iftikhar H, Saleem M, Kaji A. Pernicious Anemia Presenting as Non-ST-elevated Myocardial Infarction and Depression. Cureus 2019; 11:e4870. [PMID: 31417815 PMCID: PMC6687429 DOI: 10.7759/cureus.4870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pernicious anemia (PA) is a common cause of megaloblastic anemia throughout the world, especially in Northern European whites. This disease is characterized by the deficiency of vitamin B12 due to the presence of anti-intrinsic factor and anti-parietal cell antibodies which inhibit the absorption of the vitamin B12. In cases of severe vitamin B12 deficiency, patients can suffer debilitating complications such as described in our case.
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Affiliation(s)
- Hassaan Iftikhar
- Internal Medicine, St. Francis Medical Center, Seton Hall University, Trenton, USA
| | - Maryam Saleem
- Internal Medicine, Waterbury Hospital, Waterbury, USA
| | - Anand Kaji
- Internal Medicine, St. Francis Medical Center, Seton Hall University, Trenton, USA
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38
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Silva B, Velosa A, Barahona-Corrêa JB. Reversible dementia, psychotic symptoms and epilepsy in a patient with vitamin B 12 deficiency. BMJ Case Rep 2019; 12:12/5/e229044. [PMID: 31092496 DOI: 10.1136/bcr-2018-229044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Vitamin B12 deficiency is a common condition, typically associated with megaloblastic anaemia, glossitis and neuropsychiatric symptoms. We report the case of a patient presenting with progressive cognitive and functional deterioration, psychosis and seizures, later found to be secondary to pernicious anaemia. Importantly, the diagnosis of pernicious anaemia was only established 5 years after symptom onset and was overlooked even when the patient was under medical care, in part due to the lack of classic neurological and haematological signs associated with the condition. The patient had a remarkable neuropsychiatric recovery after vitamin replacement and psychopharmacological management. We discuss similar presentations of vitamin B12 deficiency found in the literature, symptom reversibility and the importance of its early recognition and treatment.
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Affiliation(s)
- Bruno Silva
- Psychiatry, NOVA Medical School
- Faculdade de Ciências Médicas de Lisboa and Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,CADIN-Neurodesenvolvimento e Inclusão, Cascais, Portugal
| | - Ana Velosa
- Psychiatry, NOVA Medical School
- Faculdade de Ciências Médicas de Lisboa and Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - J Bernardo Barahona-Corrêa
- Psychiatry, NOVA Medical School
- Faculdade de Ciências Médicas de Lisboa and Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,CADIN-Neurodesenvolvimento e Inclusão, Cascais, Portugal.,Neuropsychiatry Unit, Champalimaud Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
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39
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Troilo A, Grassi A, Petrone L, Cianchi F, Benagiano M, Bella CD, Capitani N, Bitetti J, D'Elios S, Tapinassi S, Azzurri A, Alnwaisri H, Romagnoli J, Bizzaro N, Bergman M, Baldari CT, D'Elios MM. Intrinsic factor recognition promotes T helper 17/T helper 1 autoimmune gastric inflammation in patients with pernicious anemia. Oncotarget 2019; 10:2921-2929. [PMID: 31080562 PMCID: PMC6499598 DOI: 10.18632/oncotarget.26874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
The intrinsic factor is the major humoral autoantigen in pernicious anemia/autoimmune gastritis. Although many studies have examined the autoantibody response to intrinsic factor and H+,K+-ATPase, no information is available on possible pathogenic mechanisms mediated by intrinsic factor - specific gastric T cells. Aim of this study was to investigate intrinsic factor-specific T cells in the gastric mucosa of pernicious anemia patients and define their functional properties. For the first time we provide evidence that gastric mucosa of pernicious anemia patients harbour a high proportion (20%) of autoreactive activated CD4+ T-cell clones that specifically recognize intrinsic factor. Most of these clones (94%) showed a T helper 17 or T helper 1 profile. All intrinsic factor-specific clones produced tumor necrosis factor-α, interleukin-21 and provided substantial help for B-cell immunoglobulin production. Most mucosa-derived intrinsic factor-specific T-cell clones expressed cytotoxicity against target cells. Our results indicate that activation of intrinsic factor-specific T helper 17 and T helper 1 T cells in the gastric mucosa represent a key effector mechanism in pernicious anemia suggesting that the T helper 17/T helper 1 pathway may represent a novel target for the prevention and treatment of the disease.
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Affiliation(s)
- Arianna Troilo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessia Grassi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luisa Petrone
- Endocrinology Unit, Careggi Hospital, Florence, Italy
| | - Fabio Cianchi
- Department of Surgery, University of Florence, Florence, Italy
| | - Marisa Benagiano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Chiara Della Bella
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Nagaja Capitani
- Department of Life Sciences, University of Siena, Siena, Italy
| | - Jacopo Bitetti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sofia D'Elios
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Simona Tapinassi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Heba Alnwaisri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | - Mathijs Bergman
- Amsterdam Institute for Molecules, Medicines and Systems, Vrije University, Amsterdam, The Netherlands
| | | | - Mario Milco D'Elios
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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40
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Abstract
Gastric neuroendocrine tumors (GNET) are rare gastric neoplasms accounting for <1% of all gastric neoplasms. The World Health Organization (WHO) categorized these neoplasms as types 1-3 to help predict malignant potential and long-term survival and guide management. Improved outcomes have been shown with endoscopic resections, but further studies are needed to confirm the best approach. We present a case of a 56-year-old woman who demonstrated the classic features of type one GNET with mucosal and submucosal involvement in the setting of primary atrophic gastritis, secondary hypergastrinemia, and underlying pernicious anemia. In general, standardizing treatment has been difficult due to a variable presentation.
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Affiliation(s)
- Hector H Gonzalez
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Mary Acosta
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - George Yazji
- Family Medicine, North Florida Regional Medical Center/ University of Central Florida College of Medicine, Gainesville, USA
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41
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Zhang N, Li RH, Ma L, Li N, Shan PY, Wang XB, Liu AF. Subacute Combined Degeneration, Pernicious Anemia and Gastric Neuroendocrine Tumor Occured Simultaneously Caused by Autoimmune Gastritis. Front Neurosci 2019; 13:1. [PMID: 30740042 PMCID: PMC6355687 DOI: 10.3389/fnins.2019.00001] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/03/2019] [Indexed: 12/27/2022] Open
Abstract
Subacute combined degeneration (SCD) is a relatively rare myelopathy mainly caused by vitamin B12 (VitB12) deficiency. There are many causes contributing to VitB12 deficiency. Autoimmune gastritis might lead to severe VitB12 malabsorption and in its advanced stage pernicious anemia (PA) may occur. Besides, long-term hypergastrinemia arising from achlorhydria in autoimmune gastritis is associated with neuroendocrine tumors (NETs). Patients diagnosed with SCD coexistent with PA and NET are seldomly reported. We describe a 34-year-old woman with an initial complaint of progressive fatigue, weakness and numbness in her limbs and disturbed gait. Physical examination revealed appearance of anemia, ataxia, decrease of superficial and deep sense, and positive Babinski’s sign. Laboratory tests disclosed macrocytic anemia, elevated intrinsic factor antibody and spinal MRI showed extensive T2-weighted hyperintensity in the dorsal columns. A gastric polyp was revealed by gastroscopy and histology showed an NET in the background of severe atrophic gastritis. Symptoms of the patient were relieved by a multidisciplinary therapy. In patients with SCD, PA should be suspected and prompt further investigations to elucidate causes and direct treatment.
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Affiliation(s)
- Nan Zhang
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Rui-Hua Li
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Lin Ma
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Na Li
- Department of Dermatology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Pei-Yan Shan
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Xing-Bang Wang
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Ai-Fen Liu
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
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42
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Salinas M, Flores E, López-Garrigós M, Leiva-Salinas C. Vitamin B12 deficiency and clinical laboratory: Lessons revisited and clarified in seven questions. Int J Lab Hematol 2018; 40 Suppl 1:83-88. [PMID: 29741251 DOI: 10.1111/ijlh.12833] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/22/2018] [Indexed: 11/26/2022]
Abstract
The objective of this review article is to address the most frequently asked questions that pathologists and primary care physicians might face when dealing with a patient with suspicion of vitamin B12 deficiency. More specifically, the article mainly discusses the importance and prevalence of the deficit, how to recognize it, and the important role of a prompt diagnosis confirmation based on laboratory biomarkers for efficient replacement therapy.
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Affiliation(s)
- M Salinas
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Spain.,Department of Biochemistry and Molecular Pathology, Universidad Miguel Hernandez, Elche, Spain
| | - E Flores
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Spain.,Department of Clinic Medicine, Universidad Miguel Hernandez, Elche, Spain
| | - M López-Garrigós
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Spain
| | - C Leiva-Salinas
- Department of Clinical Radiology, University of Missouri Health, Columbia, MO, USA
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43
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Elamami AH, Elmehdwi N, Younis EZ, Zwawi H, Elsahli R, Latiwesh OB, Hussain A. Pernicious Anemia Presented with Isolated Nominal Dysphasia in Type Ill Polyglandular Failure Female Patient. Cureus 2018; 10:e3306. [PMID: 30519517 PMCID: PMC6277171 DOI: 10.7759/cureus.3306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Pernicious anemia (also known as Biermer's disease) is an autoimmune atrophic gastritis which predominantly affects the fundus of the stomach. It results in a deficiency of vitamin B12 (cobalamin) as it affects the normal process of absorption in the ileum. The pernicious anemia is characterized by a wide range of hematological and neurological features. Neurological features can present without hematological manifestations. One of the early neurological features of this anemia is nominal dysphasia (word-finding difficulties), which was usually not reported before as an isolated finding. We present a case of pernicious anemia with isolated nominal dysphasia responding dramatically to parenteral vitamin B12 therapy.
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Affiliation(s)
| | | | - Eman Z Younis
- Laboratory Medicine, University of Benghazi, Benghazi, LBY
| | - Hamid Zwawi
- Internal Medicine, University of Benghazi, Benghazi, LBY
| | - Rabha Elsahli
- Internal Medicine, University of Benghazi, Benghazi, LBY
| | - Omar B Latiwesh
- Medical Laboratory, Higher Institute of Medical Professions, Benghazi, LBY
| | - Azhar Hussain
- Medicine, Xavier University School of Medicine, Oranjestad, ABW
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44
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Abstract
RATIONALE Pernicious anemia (PA) is an autoimmune gastritis that results from the destruction of gastric parietal cells and the associated lack of an intrinsic factor to bind ingested vitamin B12. While an association between PA and various liver diseases has been rarely reported, reports of associated diseases include primary biliary cholangitis, autoimmune hepatitis, and Interferon-treated hepatitis C. We present 2 cases of PA associated with cryptogenic cirrhosis (CC), which has not been previously reported in the literature. PATIENT CONCERNS A 42-year-old man presented with fatigue, pallor, and sustained abdominal distension that had persisted for 15 days. An 87-year-old man was admitted to the hospital for an unsteady gait and loss of appetite that had persisted for 20 days. DIAGNOSES Symptoms, laboratory tests, and imaging findings for both patients were indicative of PA and CC.Both had neurological and psychiatric symptoms during hospitalization that were ultimately linked to a vitamin B12 deficiency but not hepatic encephalopathy. INTERVENTIONS Both patients received intramuscular injections of vitamin B12. OUTCOMES Hemoglobin levels of the 2 patients increased gradually, and their neurological symptoms were alleviated. LESSONS PA associated with a liver disease is rare, and the underlying mechanism can only now be clarified. We speculate that autoimmune dysfunction and chronic vitamin B12 deficiency caused by PA might be unique causes of liver cirrhosis. Additional investigations are needed to verify these findings.
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Lin CY, Li CK, Liu JM, Hsu RJ, Chuang HC, Chang FW. Postpartum Depression and Subsequent Autoimmune Diseases in Taiwan. Int J Environ Res Public Health 2018; 15:ijerph15081783. [PMID: 30127260 PMCID: PMC6121646 DOI: 10.3390/ijerph15081783] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 12/17/2022]
Abstract
Postpartum depression (PPD) is one of the most common examples of postnatal morbidity, but the subsequent risks of autoimmune diseases in patients with PPD have yet to be fully investigated. This nationwide population-based study utilized data of the National Health Insurance Research Database of Taiwan for the period from 1996 to 2013. In total, 45,451 women with primiparity were identified. Among them, 542 patients with PPD were enrolled as a study group while 2165 matched patients without PPD were enrolled as a control group. The demographic characteristics and comorbidities of the patients were analyzed, and Cox regression analysis was applied to calculate the hazard ratios for the risk of autoimmune diseases. Of the 2707 women enrolled in this study, 469 (17.3%) patients with newly diagnosed autoimmune diseases were identified, including 123 (22.7%) in the PPD group and 346 (16%) in the non-PPD group. After adjusting for confounding factors, it was determined that the patients with PPD had a significantly higher risk of subsequent autoimmune diseases (adjusted hazard ratio (aHR): 1.61, 95% confidence interval (CI): 1.30–1.99; p < 0.001). Specifically, increased risks of pernicious anemia (aHR: 3.85, 95% CI: 2.06–7.22), rheumatoid arthritis (aHR: 2.62, 95% CI: 1.28–5.39), and Graves’ disease (aHR: 1.57, 95% CI: 1.05–2.33) were observed in the PPD group. This study demonstrated that patients with PPD have higher risks of subsequent autoimmune diseases, especially pernicious anemia, rheumatoid arthritis, and Graves’ disease. This useful information provides physicians with clues regarding the associations between autoimmune diseases and PPD.
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Affiliation(s)
- Chien-Yu Lin
- Department of Pediatrics and Infectious Disease, Hsinchu MacKay Memorial Hospital, Hsinchu City 300, Taiwan.
| | - Cheng-Kai Li
- Department of Gynecology, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan 330, Taiwan.
| | - Jui-Ming Liu
- Division of Urology, Department of Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan 330, Taiwan.
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan.
| | - Ren-Jun Hsu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan.
- Biobank Management Center of the Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan.
- Department of Pathology and Graduate Institute of Pathology and Parasitology, the Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan.
| | - Heng-Chang Chuang
- Division of Urology, Department of Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan 330, Taiwan.
| | - Fung-Wei Chang
- Department of Obstetrics & Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan.
- Superintendent, Tri-Service General Hospital Penghu Branch, National Defence Medical Center, Penghu Branch, Magong City 880, Taiwan.
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El Rassy E, Al Ghor M, Kattan J. CA 15-3 predicting breast cancer relapse: beware of vitamin B12 deficiency. Per Med 2018; 15:163-165. [PMID: 29745746 DOI: 10.2217/pme-2017-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A sustained increase of cancer antigen 15-3 serum levels was found in a 54-year-old woman treated 2 years ago for early stage breast cancer, without any evidence of cancer recurrence. The patient thereafter developed severe megaloblastic anemia secondary to vitamin B12 deficiency. Supplementation with B12 to reverse the anemia led to the normalization of the cancer antigen 15-3 serum levels. As such, with the limited understanding of molecular biology, the integrative approach of clinical history, physical examination, and diagnostic imaging remain pivotal in the management of cancer patients.
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Affiliation(s)
- Elie El Rassy
- Faculty of Medicine, Department of Hematology-Oncology, Hotel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Maya Al Ghor
- Faculty of Medicine, Department of Hematology-Oncology, Hotel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Joseph Kattan
- Faculty of Medicine, Department of Hematology-Oncology, Hotel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
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Papp F, Rácz G, Lénárt I, Kóbor J, Bereczki C, Karg E, Baráth Á. [Maternal and neonatal vitamin B 12 deficiency detected by expanded newborn screening]. Orv Hetil 2018; 158:1909-1918. [PMID: 29172662 DOI: 10.1556/650.2017.30901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Infant vitamin B12 deficiency can manifest as a severe neurodegenerative disorder and is usually caused by maternal deficiency due to vegetarian diet or pernicious anaemia. Its early recognition and treatment can prevent potentially serious and irreversible neurologic damage. Biochemically, vitamin B12 deficiency leads to an accumulation of methylmalonic acid, homocysteine, and propionylcarnitine. Expanded newborn screening using tandem mass spectrometry may identify neonatal and maternal vitamin B12 deficiency by measurement of propionylcarnitine and other metabolites in the dried blood spot sample of newborns. AIM To summarize our experiences gained by screening for vitamin B12 deficiency. METHOD Clinical and laboratory data of vitamin B12-deficient infants diagnosed in Szeged Screening Centre were retrospectively analysed. RESULTS In Hungary, expanded newborn screening was introduced in 2007. Since then approximately 395 000 newborns were screened in our centre and among them, we identified four newborns with vitamin B12 deficiency based on their screening results. In three cases an elevated propionylcarnitine level and in the fourth one a low methionine level were indicative of vitamin B12 deficiency. We also detected an additional vitamin B12-deficient infant with neurological symptoms at 4 months of age, after a normal newborn screening, because of elevated urinary methylmalonic acid concentration. Vitamin B12 deficiency was secondary to maternal autoimmune pernicious anaemia in all the five infants. As a result of the recognized cases the incidence of infant vitamin B12 deficiency in the East-Hungarian region was 1.26/100 000 births, but the real frequency may be higher. Conslusions: Optimizing the cut off values of current screening parameters and measuring of methylmalonic acid and/or homocysteine in the dried blood spot, as a second tier test, can improve recognition rate of vitamin B12 deficiency. Orv Hetil. 2017; 158(48): 1909-1918.
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Affiliation(s)
- Ferenc Papp
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
| | - Gábor Rácz
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
| | - István Lénárt
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
| | - Jenő Kóbor
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
| | - Csaba Bereczki
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
| | - Eszter Karg
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
| | - Ákos Baráth
- Gyermekgyógyászati Klinika és Gyermek-egészségügyi Központ, Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Szeged, Korányi fasor 14-15., 6720
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Liu JM, Hsu RJ, Chang FW, Chiu FH, Yeh CL, Huang CF, Chang ST, Lee HC, Chi H, Lin CY. Increased risk of pernicious anemia following scabies: a nationwide population-based matched-cohort study. Ther Clin Risk Manag 2017; 13:1205-1211. [PMID: 29066901 PMCID: PMC5605127 DOI: 10.2147/tcrm.s137662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives Scabies is a common and annoying disorder. Pernicious anemia (PA) is a serious disease which, when untreated, leads to death. Mounting evidence suggests that immune-mediated inflammatory processes play a role in the pathophysiology of both diseases. The relationship between these two diseases has not been investigated. We conducted this study to explore the potential relationship between scabies and PA. Materials and methods This nationwide, population-based study was conducted using the National Health Insurance Research Database of Taiwan. In total, 5,407 patients with scabies were identified as a study group and 20,089 matched patients were randomly selected as a control group. We tracked patients in both groups for a 7-year period to identify the incidence of PA. The demographic characteristics and comorbidities of the patients were analyzed, and Cox proportional hazards regression was used to calculate the hazard ratios for PA. Results Of the 25,496 patients in this study, 183 (0.7%) patients with newly diagnosed PA were identified during the 7-year follow-up period; 71 of 5,407 (1.3%) from the scabies group and 112 of 20,089 (0.6%) from the control group. Patients with scabies had a higher risk of subsequent PA, with a crude hazard ratio of 2.368. After adjusting for covariates, the adjusted hazard ratio was 1.51 (95% confidence interval: 1.09–2.08). Conclusion This study demonstrated an increased risk of PA (adjusted hazard ratio 1.51) among patients with scabies. Immune-mediated inflammatory processes may contribute to this association. Further studies are warranted to investigate the entire pathological mechanisms between these two diseases. Physicians should pay attention to patients with history of scabies presented with anemia. Further confirmative tests of PA may contribute to correct diagnosis and initiation of vitamin B12 supplement.
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Affiliation(s)
- Jui-Ming Liu
- Division of Urology, Department of Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan.,Department of Medicine, National Yang-Ming University.,Graduate Institute of Life Sciences
| | - Ren-Jun Hsu
- Graduate Institute of Life Sciences.,Department of Pathology and Graduate Institute of Pathology and Parasitology, the Tri-Service General Hospital, National Defense Medical Center.,Biobank Management Center of the Tri-Service General Hospital
| | - Fung-Wei Chang
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Feng-Hsiang Chiu
- Department of Emergency Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Superintendent office, Lihuili Eastern Hospital, Ningbo, Zhejiang province, People's Republic of China
| | - Chia-Lun Yeh
- Division of Urology, Department of Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan
| | - Chun-Fa Huang
- School of Chinese Medicine, College of Chinese Medicine, China Medical University.,Department of Nursing, College of Medical and Health Science, Asia University, Taichung City
| | - Shu-Ting Chang
- Department of Gastroenterology, BinKun Women's and Children's Hospital, Taoyuan City
| | - Hung-Chang Lee
- Department of Infectious Disease, MacKay Children's Hospital, Taipei
| | - Hsin Chi
- Department of Infectious Disease, MacKay Children's Hospital, Taipei.,Department of Medicine, MacKay Medical College, New Taipei city
| | - Chien-Yu Lin
- Department of Pediatrics and Infectious Disease, Hsinchu MacKay Memorial Hospital, Hsinchu City, Taiwan.,Division of Infection and Pathway Medicine, College of Medicine and Veterinary Medicine, The University of Edinburgh, Scotland, UK
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Abstract
Anemia is one of the most common health problems in the primary care setting. Macrocytosis in adults is defined as a red blood cell (RBC) mean corpuscular volume (MCV) >100 femtoliter (fL). Macrocytic anemias are generally classified into megaloblastic or nonmegaloblastic anemia. Megaloblastic anemia is caused by deficiency or impaired utilization of vitamin B12 and/or folate, whereas nonmegaloblastic macrocytic anemia is caused by various diseases such as myelodysplastic syndrome (MDS), liver dysfunction, alcoholism, hypothyroidism, certain drugs, and by less commonly inherited disorders of DNA synthesis. Macrocytic anemias are treated with cause‐specific therapies, and it is crucial to differentiate nonmegaloblastic from megaloblastic anemia. Because MDS and myeloid neoplasms commonly affect the elderly, primary care physicians may encounter more cases of macrocytic anemias in the near future, as the older population increases. When MDS is suspected along with leukocytopenia and/or thrombocytopenia with anemia, a hematology consultation may be appropriate.
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Affiliation(s)
- Takayo Nagao
- Department of General Internal Medicine and Clinical Laboratory Medicine Akita University Graduate School of Medicine Akita Japan
| | - Makoto Hirokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine Akita University Graduate School of Medicine Akita Japan
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Rogers A, Lotto C, Yeo CJ. Pancreatic Endocrine Neoplasm Concomitant with a Complicated Endocrine History: A Case Report and Literature Review. J Pancreat Cancer 2017; 3:19-22. [PMID: 30631835 PMCID: PMC5933474 DOI: 10.1089/pancan.2017.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Pancreatic neuroendocrine tumors (PNETs) are rare, and metastases when present are most commonly found in the liver or the peripancreatic lymph nodes. In this study, we present a patient who developed a metastatic PNET in the liver in the setting of multiple concomitant autoimmune disorders, including pernicious anemia and atrophic gastritis with hypergastrinemia. Case presentation: The patient is a 70-year-old woman with a history of Hashimoto's thyroiditis, thymoma, gastric carcinoid tumors, and autoimmune atrophic gastritis with pernicious anemia. She was found to have a 2 cm mass in the pancreaticoduodenal groove originating from the pancreas. A preoperative endoscopic ultrasound with fine-needle aspiration showed a well-differentiated PNET. During surgery, she was found to have multiple subcentimeter liver lesions, which on frozen section were shown to be a metastatic neuroendocrine tumor. After surgical resection, final pathology revealed a PNET with metastases to the liver. The metastatic lesions stained positive for gastrin. Conclusion: We were only able to find one other example in the literature of a PNET occurring in association with pernicious anemia. Our patient developed a metastatic PNET in the setting of multiple autoimmune disorders, including pernicious anemia.
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Affiliation(s)
- Amelia Rogers
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christine Lotto
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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