A New Case of Association of Megaloblastic Anemia and Pancytopenia of Infants

BACKGROUND

Vitamin B12, or cobalamin deficiency, an infrequent clinical entity in pediatric age, is found almost solely in breastfed infants whose mothers are purely vegetarian, non-supplemented or with pernicious anemia. Megaloblastic anemia in infants presents with generalized weakness or irritability.

METHODS

Diagnosis is usually centered on complete blood count, vitamin dosing, and peripheral smear, which may show macrocytes, hypersegmented neutrophils, reticulocytopenia and a raised mean corpuscular volume (MCV ˃ 100 fL). Pancytopenia has also been noted.

RESULTS

We report an exclusive breastfed nine-month-old female child who presented with irritability, developmental delay, and difficulties in introducing new foods. Her initial blood count revealed pancytopenia. Vitamin B12 levels were found to be reduced. Maternal levels of Vitamin B12 were also found to be borderline low. The child was treated as per protocols, and improvement was evidenced with the return of hematological parameters to the regular and gradual advancement of milestones.

CONCLUSIONS

We aim to underscore the importance of megaloblastic anemia as an important and rare cause of anemia in infancy.

Elevated IL-19 Serum Levels in Patients With Pernicious Anemia and Autoimmune Gastritis

Pernicious anemia (PA) is a megaloblastic anemia consisting of hematological, gastric and immunological alterations. The immunopathogenesis of PA is sustained by both autoantibodies (e.g. intrinsic factor (IFA) antibodies and anti parietal cell (PCA) antibodies and autoreactive T cells specific for IFA and the parietal cell proton pump ATPase. Iron deficient anemia (IDA) is a microcytic anemia and represents the most common cause of anemia worldwide. Our work aimed to investigate serum levels of several interleukins (IL) of the IL-20 cytokine subfamily in patients with PA, with IDA and in healthy subjects (HC). We compared serum levels of IL-19, IL-20, IL-26, IL-28A and IL-29 in 43 patients with PA and autoimmune gastritis, in 20 patients with IDA and no autoimmune gastritis, and in 47 HC. Furthermore, we analyzed the IL-19 cytokine production by gastric lamina propria mononuclear cells (LPMC) in eight patients with PA and four HC. We found that patients with PA have significantly higher serum levels of IL-19 (163.68 ± 75.96 pg/ml) than patients with IDA (35.49 ± 40.97 pg/ml; p<0.001) and healthy subjects (55.68 ± 36.75 pg/ml; p<0.001). Gastric LPMC from all PA patients were able to produce significantly higher levels of IL-19 (420.67 ± 68.14 pg/ml) than HC (53.69 ± 10.92 pg/ml) (p<0.01). Altogether, our results indicate that IL-19 serum levels are significantly increased in patients with PA but not with IDA and that IL-19 is produced in vivo in the stomach of PA patients. These data open a new perspective on PA pathogenesis and suggest that IL-19 may represent a novel important tool for the management of patients with PA.

Predominant tubulointerstitial lupus nephritis with preceding pernicious anemia

Predominant tubulointerstitial nephritis with negligible glomerular lesions is a rare form of lupus nephritis. Although tubulointerstitial changes occur in two-thirds of patients with lupus nephritis, these lesions were mostly accompanied by glomerulonephritis. Predominant tubulointerstitial lupus nephritis has been reported to be only 13 cases in the literature as far as we surveyed. Here, we present a case of a 72-year-old male who had pancytopenia associated with pernicious anemia and later developed a mild proteinuria and renal insufficiency. Although urinary tubulointerstitial markers increased, serological screening tests for tubulointerstitial nephritis were all negative. Three months later, the patient was diagnosed as systemic lupus erythematosus, based on polyarthritis, positive antinuclear antibody, immunological disorder and hematological disorder. Renal biopsy revealed severe infiltration of mononuclear cells in the interstitium with minimal abnormalities in glomeruli. Positive IgG and C1q staining with immunofluorescence antibody method in the tubular basement membrane and dense deposits in the same region with electron microscopy confirmed a diagnosis of predominant tubulointerstitial lupus nephritis. Since the patient's renal function declined rapidly, treatment with intravenous 500 mg methyl prednisolone followed by 40 mg/day of oral prednisolone was initiated. The patient's renal function improved and became stable even after tapering of prednisolone. Although lupus nephritis is generally accompanied by multiple symptoms such as fever, malaise, arthralgia, rashes, this case showed only pernicious anemia and tubulointerstitial nephritis initially.

[A Case of Advanced Cardia Gastric Cancer with Pernicious Anemia]

A 70s male was referred to our hospital with anemia that was detected during a medical checkup. Upper gastrointestinal endoscopy showed advanced cardia gastric cancer. A diagnosis of pernicious anemia was made due to the macrocytic hyperchromic anemia and detection of intrinsic factor antibody. A CT scan showed fundic wall thickening and regional lymph node metastasis. After anemia improved following vitamin B12 injection, total gastrectomy with lymphadenectomy was performed. The histopathological findings showed adenocarcinoma(tub1>tub2), Type2 , pT3(SS), pN1(2/24), Stage ⅡB, INF b, ly1, v2, PM0, DM0, EW(+), pR1. He was administered systematic chemotherapy using S-1 for one year after surgery and has been followed up without recurrence for 5 years.

HIGH-RISK GASTRIC PATHOLOGY AND PREVALENT AUTOIMMUNE DISEASES IN PATIENTS WITH PERNICIOUS ANEMIA

OBJECTIVE

Pernicious anemia (PA) develops from atrophic gastritis due to autoimmune destruction of parietal cells and results in achlorhydria, vitamin B12 and iron deficiencies, anemia, neurologic deficits, and premalignant and malignant stomach lesions. We report the presentation, diagnosis and gastric complications of PA in patients from an endocrinology practice.

METHODS

Thirty-four patients (31 female, 3 male) with PA who underwent esophagogastroduodenoscopy (EGD) or gastrectomy were identified. Pertinent clinical, laboratory, and pathology findings were reviewed and summarized.

RESULTS

The mean age of patients was 58.6 ± 14.2 years; the onset of PA was age 50.2 ± 15.3 years. Anemia reflected vitamin B12 and/or iron deficiencies. Parietal cell antibodies (PCA) were detected in 97% of patients, and intrinsic factor blocking antibody (IFBA) was found in 52%. Fasting gastrin and chromogranin A levels were elevated (1,518.0 ± 1,588.3 pg/mL, and 504.9.1 ± 1,524.9 ng/mL respectively). Autoimmune or immunologic diseases (AIDs) were present in 32/34 patients. Stomach pathology showed premalignant or malignant lesions in 26 patients, including gastric neuroendocrine tumors (GNETs) in 6 and adenocarcinoma in 1. One patient presented with neurologic symptoms and subacute combined degeneration of the posterior column of the spinal cord.

CONCLUSION

PA should be suspected in patients with unexplained anemia or neurologic symptoms. The diagnosis of PA relies on fasting gastrin and gastric auto-antibody testing, in addition to hematologic evaluation. EGD with measurement of gastric pH and biopsies of the fundus and antrum identifies patients with achlorhydria, atrophic gastritis, and premalignant and malignant stomach lesions. EGD surveillance of patients with high-risk stomach lesions is recommended.

ABBREVIATIONS

AID = autoimmune or immunologic disease; EGD = esophagogastroduodenoscopy; GNET = gastric neuroendocrine tumor; IFBA = intrinsic factor blocking antibody; PA = pernicious anemia; PCA = parietal cell antibody; T1D = type 1 diabetes.

Vitamin B12 deficiency from the perspective of a practicing hematologist

B₁₂ deficiency is the leading cause of megaloblastic anemia, and although more common in the elderly, can occur at any age. Clinical disease caused by B₁₂ deficiency usually connotes severe deficiency, resulting from a failure of the gastric or ileal phase of physiological B₁₂ absorption, best exemplified by the autoimmune disease pernicious anemia. There are many other causes of B₁₂ deficiency, which range from severe to mild. Mild deficiency usually results from failure to render food B₁₂ bioavailable or from dietary inadequacy. Although rarely resulting in megaloblastic anemia, mild deficiency may be associated with neurocognitive and other consequences. B₁₂ deficiency is best diagnosed using a combination of tests because none alone is completely reliable. The features of B₁₂ deficiency are variable and may be atypical. Timely diagnosis is important, and treatment is gratifying. Failure to diagnose B₁₂ deficiency can have dire consequences, usually neurological. This review is written from the perspective of a practicing hematologist.

Pernicious anemia in a young man with systemic lupus erythematosus

Association of pernicious anemia and systemic lupus erythematosus is rare, although both diseases are autoimmune origin. We describe the case of a 40-year old man with systemic lupus erythematosus (SLE) who developed pernicious anemia. The cobalamin deficiency was revealed by macrocytic pancytopenia. After 1 month of vitamin B12 treatment, hemoglobin and white blood cell count remain normal but thrombocytopenia persists and was considered as immunologic from SLE origin requiring corticosteroids. Lupus (2007) 16, 827—829.

Updated features associated with type 1 gastric carcinoids patients: a single-center study

OBJECTIVE

Data on clinical presentation and associated features of patients with type 1 gastric carcinoids (T1-GCs) are scanty. This study aimed to provide detailed data on a series of patients with T1-GCs.

MATERIAL AND METHODS

Clinical, laboratory, endoscopic, and histological data were assessed from 31 T1-GCs patients (cross-sectional design), consecutively diagnosed in a tertiary center according to a standardized diagnostic protocol. T1-GCs were diagnosed at baseline or follow-up gastroscopy for atrophic gastritis in 74.2% and 25.8% of patients, respectively.

RESULTS

Seventy-one percent of T1-GC patients were female. Age ranged from 23 to 78 (median 58 years). T1-GCs were more frequently diagnosed between 40-49 years (35.5%) and 60-69 years (32.3%) (p = 0.0383). Thyroid disease was present in 54.8% (in 29% autoimmune). All 31 patients had either cobalamin or iron deficiency with or without anemia. Manifest pernicious anemia was present in 67.7% of patients and cobalamin deficiency without anemia in 9.7% patients. Iron deficiency anemia was present in 29% and iron deficiency without anemia in 12.9% of patients. In 48.4% of patients, T1-GCs appeared as polyps, which were single in all cases and had a median size of 4 mm (range 2-15 mm). In patients with polypoid T1-GCs, thyroid disease of autoimmune and nonautoimmune origin (p = 0.0181) was more frequently associated.

CONCLUSION

This study shows that T1-GCs may be diagnosed at any age. Autoimmune features are frequently present as well as cobalamin and iron deficiency. The copresence of autoimmune diseases and micronutrient deficiencies should be accurately investigated, in particular in patients with polypoid T1-GCs.

Effectiveness of the National Program of Complementary Feeding for older adults in Chile on vitamin B12 status in older adults; secondary outcome analysis from the CENEX Study (ISRCTN48153354)

BACKGROUND

Older people are at increased risk of vitamin B12 deficiency and the provision of fortified foods may be an effective way to ensure good vitamin B12 status in later life.

AIM

To evaluate the effectiveness of a vitamin B12 fortified food provided by a national program of complementary food for older people on plasma vitamin B12 levels.

SUBJECTS AND METHODS

A random sub-sample of 351 subjects aged 65-67 y from a large cluster randomised controlled trial provided blood samples at baseline and after 24 months of intervention. The intervention arm (10 clusters 186 participants) received a vitamin B12 fortified food designed to deliver 1.4 μg/day, while the control arm did not receive complementary food (10 clusters, 165 participants). Serum vitamin B12 and folate levels determined by radioimmunoassay were used to estimate the effect of intervention on vitamin B12 levels, adjusting for baseline levels and sex.

RESULTS

Attrition at 24 months was 16.7% and 23.6% in the intervention and control arms respectively (p = 0.07). Over 24 months of intervention, mean (95% CI) serum vitamin B12 decreased from 392 (359-425) pmol/dL to 357 (300-414) pmol/dL (p < 0.07) in the intervention arm and from 395 (350-440) pmol/dL to 351 (308-395) pmol/dL in the control arm. There was no significant effect of the intervention on folate status.

DISCUSSION

Our findings suggest that foods fortified with 1.4 μg/daily vitamin B12 as provided by Chile's national programme for older people are insufficient to ensure adequate vitamin B12 levels in this population. Chile has a long and successful experience with nutrition intervention programs; however, the country's changing demographic and nutritional profiles require a constant adjustment of the programs.

A pernicious leucoencephalopathy

Pernicious anaemia may manifest various neurological symptoms and signs ranging from the subtle to the dramatic. We describe a young man with cobalamin deficiency presenting with sensorimotor deficits, ataxia, dysarthria, mild cognitive deterioration and altered mood of insidious onset. The MRI brain findings were in keeping with a leucoencephalopathy without evidence of MRI changes in the spinal cord. This constellation of features has been reported rarely. His response to treatment as well as the marked improvement of the leucoencephalopathy on imaging suggests at least partial reversibility of the neurological deficits.

Paralysis and pernicious anemia in a young woman

Vitamin B12 is important for normal nervous system functioning, and deficiencies are associated with various neurological abnormalities. We present a case of an 18-year-old woman who presented with significant neurological sequelae, but only mild hematologic abnormalities and normal vitamin B12 levels. She was found to have a moderately increased mean corpuscular volume, a markedly elevated homocysteine level, and a greatly increased methylmalonic acid level. In symptomatic patients it is important for physicians to maintain a high index of suspicion for B12 deficiency despite normal serum levels. The measurement of MMA and homocysteine levels provides much more sensitive tests, but even these tests do not completely rule out a deficiency. Although, the traditional treatment for vitamin B12 deficiency has been intramuscular cobalamin injections, recent studies have shown that oral cobalamin may be as efficacious.

Malabsorption of vitamin B12 in dermatitis herpetiformis and its association with pernicious anaemia

Serum vitamin B12 concentrations were determined in 129 patients and a pentagastrin test performed in 116 patients with dermatitis herpetiformis (DH). Low serum vitamin B12 levels were found in 27 patients (21%) and achlorhydria in 30. Forty-two patients with achlorhydria and/or vitamin B12 deficiency were subjected to further haematological and gastrointestinal investigations. Functional or morphological involvement of the small intestine was seen in almost all patients with vitamin B12 deficiency but, in addition, atrophic gastritis resulting in defective secretion of intrinsic factor (pernicious anaemia) was found in 8 cases (7% of all DH patients). Thus, a low vitamin B12 level in DH patients should result in a careful gastrointestinal examination as both an atrophic gastritis and a coeliac-like enteropathy have further clinical implications.

Castle's test (with vitamin B12 and normal gastric juice) in the ileum in patients with genuine and patients with tapeworm pernicious anaemia

A mixture of vitamin B12 and normal gastric juice, instilled through an intestinal tube into the ileum, produces haematological remission in patients with tapeworm pernicious anaemia. When a similar mixture is administered by mouth, this effect fails to occur. This observation constitutes evidence in favour of the view that Diphyllobothrium latum, attached to the proximal portion (jejunum) of the intestine, absorbs the vitamin B12 contained in the food, thus preventing vitamin bound to the intrinsic factor of the gastric juice from reaching the receptors in the distal portions of the small intestine of the host. In genuine pernicious anaemia, remission results from the administration of vitamin B12+gastric juice both by mouth and into the ileum.

[Helicobacter pylori infection is not associated with pernicious anemia in Japan]

At present, the etiologic relationship between pernicious anemia and H. pylori infection remains unknown because different rates of positivity have been reported. To investigate the relationship of these two entities, 16 Japanese patients diagnosed with pernicious anemia were examined for H. pylori infection. Serological tests for H. pylori-IgG antibody and gastric biopsy were performed. These 16 patients ranged in age from 34 to 93 years, with a mean age of 68.1 years. They were all negative for H. pylori-IgG antibody and H. pylori on gastric biopsy. Considering that the H. pylori-positive rate in the Japanese population of the same age (60 years) is 70-80%, the findings of this study suggest that the rate of H. pylori positivity in patients with pernicious anemia is low.

Megaloblastic anaemia in vegetarian Asians

Of 27 Asians with a megaloblastic bone marrow, 22 (81%) had nutritional deficiency of vitamin B12 (NMA), while five (19%) had true pernicious anaemia (PA). All the patients were Hindu vegetarians except for a single Muslim who had PA. Dietary intakes of calories, protein, iron, vitamin B12 and folate were below the recommended level in both groups. The PA group had lower levels of serum B12 and higher levels of serum folate than the NMA group. Despite low levels of red cell folate (RCF) in the NMA patients, the abnormality in deoxyuridine (dU) suppression was always corrected by vitamin B12. The dU suppressed value showed a significant inverse relationship to the RCF level. Nutritional deficiency of vitamin B12 is the most common cause of megaloblastic anaemia in Hindu vegetarians but the incidence of true PA is higher than previously thought and may approximate to that of the white population.

Helicobacter pylori link to pernicious anaemia

An immunological classification of chronic gastritis based on the detection of Helicobacter pylori (H. pylori) antibody, parietal cell antibody, intrinsic factor antibody, is reported. H. pylori chronic gastritis, slowly progresses to atrophic gastritis, in the majority of patients; in a few patients, with genetic susceptibility to form intrinsic factor antibody, it progresses to pernicious anaemia. In majority of patients of pernicious anaemia, H. pylori gradually disappears from the gastric mucosa, on development of intestinal metaplasia in them. Atrophic gastritis results from H. pylori or non H. pylori. H. pylori infection is diagnosed in the presence of H. pylori in the gastric mucosal biopsy and/or H. pylori antibody (IgG) in the serum. The presence of the genetic factor (intrinsic factor antibody) is essential for the diagnosis of pernicious aneamia. Pernicious anaemia patients without intrinsic factor antibody, should be correctly diagnosed as atrophic gastritis, in view of the absence of the genetic factor (intrinsic factor antibody) in them.

[Study on histogenesis of enterochromaffin-like carcinoid in autoimmune atrophic gastritis associated with pernicious anemia]

BACKGROUND/AIM

Autoimmune atrophic fundic gastritis induces the pernicious anemia (PA), as well as the changes in both epithelium and endocrine cells of gastric mucosa. The most important complications are: achlorhydria, hypergastrinemia, gastric cancer and enterochromaffin-like (ECL) carcinoid. The aim of this study was to examine ECL carcinoid histogenesis in A-gastritis associated with PA.

METHODS

During the period from 2000-2006, 65 patients with PA and 30 patients of the control group were examined. Histopathological examination was done in endoscopical biopsies of gastric mucosa fixed in 10% formaldehyde. Paraffin sections were stained with classic hematoxylin-eosin (HE); histochemical AB-PAS (pH 2.5), cytochemical argyrophilic Servier-Munger's and immunocytochemical PAP methods for G cell identification and chromogranin A antibodies - specific marker for neuroendocrine ECL cells. Both G and ECL cells were counted per 20 fields, of surface 0.0245312 mm2 by a field. Basal gastrin serum levels were also examined by using radioimmunoassay (RIA) method. The obtained results were statisticaly calculated by using Student's t test.

RESULTS

Marked antral G cell hyperplasia associated with corporal ECL hyperplasia was found. ECL cell hyperplasia was of simplex, linear, adenomatoid type to the pattern of intramucous ECL cell carcinoid. An average number of G cells was statistically significant in the patients with PA as compared to the control group (p < 0.05) as well as an average number of ECL cells.

CONCLUSION

We concluded that antral G cell hyperplasia accompanied by gastrinemia induces ECL hyperplasia and ECL corporal carcinoid in A-gastritis and that their histogenesis develops trough simple, linear and adenomatoide hyperplasia.

New pathogenesis of the cobalamin-deficient neuropathy

Subacute combined degeneration (SCD) is considered the neurological counterpart of pernicious anaemia because it is the paradigmatic neurological manifestation of acquired vitamin B12 (cobalamin (Cbl)) deficiency in adulthood. Hitherto, the theories advanced to explain the pathogenesis of SCD have postulated a causal relationship between SCD lesions and the impairment of either or both of two Cbl-dependent reactions. We have identified a new experimental model, the totally gastrectomised (TGX) rat, to reproduce the key morphological features of the disease, and found new mechanisms responsible for the pathogenesis of SCD. We have demonstrated that the neuropathological lesions in TGX rats are not only due to mere vitamin withdrawal but also to the overproduction of the myelinolytic tumour necrosis factor (TNF)-alpha, nerve growth factor, the soluble(s) CD40:sCD40 ligand dyad, and the reduced synthesis of the neurotrophic agents, epidermal growth factor and interleukin-6. Cbl replacement treatments normalised all of these abnormalities.

Coexistence of megaloblastic anemia and iron deficiency anemia in a young woman with chronic lymphocytic thyroiditis

Pernicious anemia is a megaloblastic anemia caused by vitamin B12 deficiency, and is the end-stage of autoimmune gastritis that typically affects persons older than 60 years. It is the most common cause of vitamin B12 deficiency. Pernicious anemia can also be diagnosed concurrently with other autoimmune diseases. We report the occurrence of megaloblastic anemia in a 22-year-old woman with chronic autoimmune thyroiditis for 10.5 years. Recently, she presented with microcytic anemia, and iron deficiency anemia was diagnosed initially. After administration of ferrous sulfate, macrocytic anemia was revealed and vitamin B12 deficiency was detected. Pernicious anemia was highly suspected because of the endoscopic finding of atrophic gastritis, and high titer of antigastric parietal cell antibody, as well as elevated serum gastrin level. After intramuscular injections of hydroxycobalamine 100 microg daily for 10 days, and monthly later, her blood counts returned to normal.

Murine experimental autoimmune gastritis models refractive to development of intrinsic factor autoantibodies, cobalamin deficiency and pernicious anemia

Researchers have developed murine lymphopenic, non-lymphopenic, transgenic, spontaneous and infectious agent based models to induce an experimental autoimmune gastritis (EAG) for the study of human organ-specific autoimmune disease. These models result in a chronic inflammatory mononuclear cell infiltrate in the gastric mucosa, destruction of parietal and zymogenic cells with autoantibodies reactive to the gastric parietal cells and the gastric H+/K+ ATPase (ATP4), arguably hallmarks of a human autoimmune gastritis (AIG). In the case of AIG, it is well documented that, in addition to parietal cell antibodies being detected in up to 90% of patients, up to 70% have intrinsic factor antibodies with the later antibodies considered highly specific to patients with pernicious anemia. This is the first report specifically investigating the occurrence of intrinsic factor antibodies, cobalamin deficiency and pernicious anemia in EAG models. We conclude, in contrast to AIG, that, in the three EAG models examined, intrinsic factor is not selected as a critical autoantigen.

Long-term effects of elevated gastrin levels on calcitonin secretion

Gastrin and pentagastrin stimulate thyroid C cells and elevate serum calcitonin levels. Gastrin levels may be elevated when histamine-2 receptor blockers (H2RB) and/or proton pump inhibitors (PPI) are used, or in patients with pernicious anemia (PA). This study was designed to investigate the long-term effects of elevated gastrin levels on serum calcitonin levels. We conducted a pentagastrin stimulation test to evaluate C cell reserves in patients who had been using PPI and/or H2RB for an extended period, as well as in patients with PA. We compared the results with a healthy control group of similar age and sex. A total of 40 controls (26 women, 24 men) and 25 patients (15 women, 10 men) using H2RB and/or PPI, and 37 patients (24 women, 13 men) with PA were enrolled. The groups were similar in terms of mean age and sex distribution. Mean fasting gastrin levels, and mean baseline and pentagastrin-stimulated calcitonin levels were significantly higher in the H2RB+PPI and PA groups than in controls. No significant differences were observed between the H2RB+PPI and PA groups. There was no correlation between gastrin and calcitonin levels. However, mean calcitonin levels were significantly higher in subjects with high baseline gastrin levels than in controls. The prevalence of autoimmune thyroid disease was 32% in the PA group. Patients with PA and thyroiditis had significantly higher baseline gastrin levels than patients with PA only (p<0.01). PA with autoimmune thyroid disease had also significantly higher baseline and pentagastrin-stimulated calcitonin levels than did PA patients without autoimmune thyroid disease. In conclusion, chronic elevated gastrin levels led to elevated calcitonin levels. Further histopathological studies showing C cell hyperplasia are needed to confirm the mechanism of this relationship.

[Neurological manifestations of vitamin B12 deficiency: a retrospective study of 26 cases]

PURPOSE

Neurological symptoms of B12 vitamin deficiency are polymorph. Causes are dominated by Biermer's disease and B12 vitamin non dissociation that is frequent in the elderly.

METHODS

We realized a retrospective study during 11 years. Patients with neurological symptoms associated to megaloblastosis were included. Treatment with B12 vitamin lead to haematological manifestation regression.

RESULTS

26 cases were analyzed. Mean age was 50+/-14.5 years and there were 11 women and 15 men. Neurological signs included combined medullar sclerosis (N = 10), peripheral neuropathy (N = 10), isolated paresthesia (N = 5) and inferior limb pyramidal syndrome (N = 1). Neurological signs revealed vitamin B12 deficiency in 4 cases. Mean haemoglobin rate was 6.2+/-2.6 g/dl, mean MCV was 109+/-56 fl. Eight patients had macrocytic anaemia, nine bi-cytopenia and eight deep pancytopenia. Electromyography (N = 8) confirmed neuropathy and medullar MRI (N = 2) showed antero-posterior cordonal demyelinisation of cervico-dorsal medulla. Causes of B12 vitamin deficiency were Biermer's disease (N = 11), non dissociation of B12 vitamin's syndrome (N = 8) and partial gastrectomy (N = 1). In 6 patients, no aetiology was found. Treatment with parenteral vitamin B12 induced neurological symptoms regression in 14 cases. Patient with neurological disorder had significantly higher platelet count and haemoglobin level as compared with patients without neurological disorder. Reticulocyte crisis was more precocious in patients with neurological disorders.

CONCLUSION

Neurological symptoms in vitamin B12 deficiency are frequent. We insist on isolated forms, inaugural forms and on the interest of medullar MRI for early diagnosis.

Vitamin B12: chemistry and biochemistry

Vitamin B12, the 'antipernicious anaemia factor', is required for human and animal metabolism. It was discovered in the late 1940s and its unique corrin ligand was revealed approx. 10 years later by X-ray crystallography. The B12-coenzymes are cofactors in various important enzymatic reactions and are particularly relevant in the metabolism of anaerobic microorganisms. Microorganisms are the only natural sources of the B12-derivatives, whereas most spheres of life (except for the higher plants) depend on these cobalt corrinoids.

[Atypical presentation of common variable immunodeficiency without infections]

BACKGROUND

Common variable immunodeficiency (CVID) is a primary immunodeficiency disease, the hallmark of which is hypogammaglobulinemia and poor specific antibody responses. Patients usually have recurrent bacterial infections, but there are a number of other comorbid disorders, including autoimmune disease and neoplasms. Most patients are diagnosed as adults, and delay in identifying the antibody defect is common. In the present report, we illustrate atypical initial presentation without infections in CVID.

CLINICAL OBSERVATION

In 5 out of 30 patients with CVID (16.6 %) diagnosed in our hospital in the Autonomous Community of Madrid, the first manifestation of immunodeficiency was not an infection. Three patients presented with immune cytopenias (thrombocytopenic purpura [n = 2] and hemolytic anemia [n = 1]); one patient had pernicious anemia and one patient had insulin-dependent diabetes as the first clinical feature of CVID. Four patients had IgG levels below 400 mg/dl.

CONCLUSIONS

Atypical presentations of CVID must be recognized to prevent delayed diagnosis. Presentation of CVID as an autoimmune disease in the absence of recurrent infections prompts us to suggest baseline testing of immunoglobulin levels in patients presenting with autoimmune disorders.

[Is there a link between the food-cobalamin malabsorption and the pernicious anemia?]

BACKGROUND

A relation between food-cobalamin malabsorption and pernicious anemia has been suggested, particularly in the event of food-cobalamin malabsorption related to hypochlorhydric atrophic gastritis.

STUDY DESIGN

This work describes three cases of well-documented cobalamin deficiency related to food-cobalamin malabsorption in three women aged 56, 82 and 68 Years who had atrophic gastritis (not associated with Helicobacter pylori infection) and later developed authentic pernicious anemia.

CONCLUSIONS

This work illustrates the potential relation between these two disorders responsible for cobalamin deficiency.

Vitamin B12 deficiency as a worldwide problem

Pernicious anemia is a common cause of megaloblastic anemia throughout the world and especially in persons of European or African descent. Dietary deficiency of vitamin B12 due to vegetarianism is increasing and causes hyperhomocysteinemia. The breast-fed infant of a vitamin B12-deficient mother is at risk for severe developmental abnormalities, growth failure, and anemia. Elevated methylmalonic acid and/or total homocysteine are sensitive indicators of vitamin B12-deficient diets and correlate with clinical abnormalities. Dietary vitamin B12 deficiency is a severe problem in the Indian subcontinent, Mexico, Central and South America, and selected areas in Africa. Dietary vitamin B12 deficiency is not prevalent in Asia, except in vegetarians. Areas for research include intermittent vitamin B12 supplement dosing and better measurements of the bioavailability of B12 in fermented vegetarian foods and algae.