Megaloblastic anemia due to vitamin B12 deficiency – Chronic
Definition
A macrocytic anemia caused by a deficiency in cobalamin (vitamin B12) that affects erythropoiesis
Medical History
* Vitamin B12 deficiency anemia due to dietary causes
* Alcohol Abuse
* Pernicious anemia
* Intestinal malabsorption
* Gastrectomy
* Megaloblastic anemia due to fish tapeworm
Findings
* Altered mental status
* Aphthous ulcer of mouth
* Asthenia
* Bleeding gums
* Decreased vibratory sense
* Depression - Chronic
* Fatigue
* Glossodynia
* Pallor
* Paresthesia
* Poor balance
* Poor concentration
* Tinnitus
Tests
All patients with suspected vitamin B12 deficiency megaloblastic anemia should have a CBC with WBC differential.
* Complete blood count with white cell differential, manual
Anemia
* Peripheral blood smear examination, light microscopy: Blood smear examination is indicated in the initial evaluation of suspected or unexplained anemia .
Folate deficiency is often present with vitamin B12 deficiencies and should be evaluated with a RBC folate level.
* Folic acid measurement, RBC
Screening for iron deficiency anemia
* Measurement of total hemoglobin concentration: Two Hgb values below the accepted threshold are presumptive for iron-deficiency anemia. The diagnosis can be confirmed if hgb values rise to 1 g/dL or greater after 4 weeks of iron supplementation therapy .
Suspected anemia
* Hematocrit determination: Very mild anemias are associated with few or no clinical signs or symptoms; therefore, a mild anemia usually is first detected from a screening measurement of Hgb or HCT.
Suspected gastritis
* Esophagogastroduodenoscopy: Endoscopic findings for gastritis range from normal appearing mucosa to erythema, petechiae, erosions, ulcerations, or thickened folds .
Suspected or known anemia
* Reticulocyte count: The reticulocyte count is essential for differentiating between anemias arising from nonfunctional versus functional bone marrow .
Suspected pernicious anemia
* Schilling test: Stage I Schilling test should be abnormal in pernicious anemia; normal stage II results are confirmatory .
Suspected pernicious anemia
* Intrinsic factor antibody measurement: The presence of intrinsic factor antibody type II with low serum vitamin B12 levels may help diagnose pernicious anemia .
Suspected vitamin B12 (cobalamin) deficiency secondary to pernicous anemia
* Serum vitamin B12 measurement: Serum cobalamin levels below 74 pmol/L indicate a probable cobalamin deficiency .
Vitamin B12 deficient patients will have a macrocytic anemia/erythrocyte mean corpuscular volume (MCV) over 100.
* Erythrocyte mean corpuscular volume determination
While less specific and sensitive for folate deficiency than an RBC folate level, a serum folate level may used to aid in diagnosing a concomitant folate deficiency.
* Folic acid measurement, serum
Differential Diagnosis
* ETHANOL
* Disease of liver
* Hypothyroidism - Chronic
* METHOTREXATE AND RELATED AGENTS
* AIDS ANTIVIRAL NUCLEOSIDES
* AIDS ANTIVIRAL PROTEASE INHIBITORS
* Megaloblastic anemia due to chronic hemolytic anemia
* Megaloblastic anemia due to folate deficiency - Chronic
* Megaloblastic anemia due to gastrectomy
* Malabsorption syndrome
* Megaloblastic anemia due to congenital deficiency of intrinsic factor
* Megaloblastic anemia due to fish tapeworm
* Pancreatic insufficiency
* Pernicious anemia
* Celiac disease - Chronic
* Megaloblastic anemia due to disease of small intestine
* Megaloblastic anemia due to vegetarianism
Treatment
Drug Therapy
Patients following vegan diets
HYDROXOCOBALAMIN
Adults: 1 mg orally once daily
CYANOCOBALAMIN
Adults: One spray (500 mcg) into one nostril once weekly
Pernicious anemia
HYDROXOCOBALAMIN
Adults: 1 mg IM daily for 1 week OR every 2 to 4 days for 6 doses; then weekly for 1 month, then monthly OR every 3 months for life
Pernicious anemia in remission after intramuscular therapy in patients with no nervous system involvement
CYANOCOBALAMIN
Adults: One spray (500 mcg) into one nostril once weekly
Vitamin B12 deficiency megaloblastic anemia
HYDROXOCOBALAMIN
Adults: 1 mg IM every 2 to 4 days for 6 doses; then 1 mg IM every month OR 1000 mcg orally once daily
HYDROXOCOBALAMIN
Adults: hydroxocobalamin 1 to 5 mg orally daily AND folic acid 1 to 5 mg orally daily
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