Nikoletta Daoulari
Hospital Brugmann Bruxelles, Belgium
Biography
Nikoletta Daoulari is a Internal Medicine Resident at General Hospital of RIO, University of Patras, Greece. Her research interestis Internal Medicine. She also worked as Assistant in Emergency Department at Hospital Brugmann Bruxelles.
Abstract
Background: Deficiency of vitamin B12 (cobalamin) is a well-known cause of megaloblastic anemia. It is a reversible cause of bone marrow failure and demyelinating nervous system disorder, hence early detection and prompt treatment of vitamin B12 deficiency is essential. Documented symptomatic pancytopenia related to B12 deficiency is very rare representing less than 5% cases making the diagnosis in Emergency Department more challenging.
Clinical case: A 52-year -old woman with a history of Graves Basedow disease is sent by her generalist to the emergency department to be transfused for severe anemia found in blood test without any other information. She complaints of extreme tiredness and dyspnea at the least effort aggravated this past week without signs of melena or hematemesis. She describes having lost 13 kilos in a 3-month period and loss of appetite. No chest pain but sometimes palpitations. She has been put on propylthiouracil stopped 2 months ago. No others medications, no drugs but consummation of alcohol 2-3 glasses per day the last 25 years. In physical examination she is pale and icteric but the rest is normal. She has no fever and her electrocardiography reveals sinus rhythm without evidence of myocardial ischemia.
Laboratory testing reveals a profound pancytopenia with severe macrocytosis, no blasts, LDH 4860 UI/L and indirect bilirubin 1,6 mg/dL. The rest was normal.
Further workup for the cause of pancytopenia revealed non-measurable levels of B12 and folic acid. Direct Coombs was negative
Treatment with intramuscular injection of B12 and folic acid pos was started and control with abdominal scanning and gastroscopy were scheduled during hospitalization to investigate the cause of B12 deficiency
After one week of treatment laboratory testing control shows retreat of pancytopenia
Conclusions: Vitamin B12 deficiency is a rare condition and the presentation with severe pancytopenia is challenging for the emergency physicians. Prompt treatment in emergency department without waiting the results of levels of B12 must be considered to avoid deterioration of neurological condition with serious consequences for the quality of patient’s life.