Pernicious Anemia and Vitamin B12 Deficiency Presenting As Pseudothrombotic Microangiopathy and Developing Secondary Thrombocytopenia After Treatment: A Case Report - Cureus

We contiguous a 68-year-old antheral with a past of intoxicant usage upset who presented to the exigency section (ED) with generalized weakness, fatigue, and shortness of breath. The diligent denied experiencing thorax pain, palpitations, dizziness, abdominal pain, nausea, vomiting, changes successful bowel habits, fever, and changes successful appetite. On presentation, the diligent had a humor unit of 80/50 mmHg, a pulse complaint of 95 beats per minute, a respiratory complaint of 16 cycles per minute, and a assemblage somesthesia of 98.6 F. The diligent was alert, awake, and oriented to time, place, and idiosyncratic during the examination. However, He appeared jaundiced, pale, weak, and stressed. There were nary evident murmurs successful S1 oregon S2 during the cardiac examination. During a thorax examination, determination are large vesicular sounds and close little lobe crackles. Abdominal introspection revealed nary hepatosplenomegaly oregon tenderness. A neurological introspection revealed nary abnormalities and nary swelling successful the little extremities.

ED investigations were important for terrible anemia, thrombocytopenia, mild leukocytosis, acute kidney injury, indirect hyperbilirubinemia, transaminitis, compensated metabolic acidosis with debased bicarbonate and elevated procalcitonin. Troponin, D-dimer, Lipase, and Ethanol levels were wrong mean range. Chest x-ray revealed close little lobe pneumonia. (Table 1).

In the exigency department, the diligent received 2 liters of IV mean saline, Piperacillin-tazobactam 3.375 g IV, Vancomycin 1 gram IV, Paracetamol 975 mg tablet oral, Chlordiazepoxide 50 mg IV, and Pantoprazole 40 mg IV. The diligent received 1 packed RBC aft cross-matching was confirmed. The diligent was admitted to the intensive attraction portion (ICU) for attraction of pneumonia and terrible symptomatic anemia.

After infirmary admission, the diligent was transfused with 4 packed reddish humor cells and continued receiving IV antibiotics and IV fluids. Further humor enactment for anemia revealed debased serum iron, debased TIBC, precocious Ferritin level, debased serum vitamin B12 level, elevated reticulocyte percent, debased reticulocyte scale and mean implicit reticulocytic number (Table 2).

The abdominal US excluded biliary obstruction. Further investigations revealed LDH: 225 (n: 100-250 U/L), haptoglobin: 91 (n: 41-165) mg/dL, ADAMTS 13 enactment of 63% (n: 50%-100%) and schistocytes successful the peripheral humor smear. Anti-intrinsic origin antibody was importantly precocious astatine 218.6 AU/ML (n: 0.0-1.1), portion MMA and homocysteine were not collected. This diligent was diagnosed with PA based connected the operation of debased serum vitamin B12 and precocious anti-intrinsic origin antibody levels. Vitamin B12 was prescribed astatine a precocious dose of 1,000 ug iv regular successful the 5th time of admission. After stabilizing his condition, the diligent was transferred to the level for further management. The diligent was transferred from the ICU to a ward. Follow-up labs were explained successful Table 3.

In the discourse of PA with reactive thrombocytosis aft vitamin B12 correction, the diligent was diagnosed with pseudo-thrombotic microangiopathy owed to vitamin B12 deficiency Following the stabilization of the patient's condition, the diligent was discharged from the infirmary and instructed to travel up with the outpatient hematology clinic.

TTP is characterized by acute hemolytic anemia, thrombocytopenia, bleeding factors, depletion, and organ damage. Vitamin B12 deficiency is associated with akin criteria [6]. Vitamin B12 plays a important relation successful the bony marrow's maturation of reddish humor cells. Decreased levels of B12 tin effect successful macrocytic hypochromic anemia, which leads to the demolition of peripheral humor RBCs. Vitamin B12 deficiency is associated with a wide scope of hematologic manifestations. Symptoms of vitamin B12 deficiency see anemia, leukopenia, thrombocytopenia, hyper-segmented neutrophils, and pancytopenia. The incidence of pseudo-TTP is estimated to beryllium 2.5% [7].

Andres et al. [8] studied the imaginable hematological complications of vitamin B12 deficiency successful 201 patients and described “pseudo” thrombotic microangiopathy successful 2.5 % of the studied populations. Tadakamalla et al. reported a lawsuit of a 31-year-old female with a past of fatigue and paresthesia successful some legs for 1 week. Indirect hyperbilirubinemia, thrombocytopenia, and schistocytes were recovered with subacute onset of fatigue and paresthesia, and TTP was suspected. However, platelet number did not amended with 4 days of plasmapheresis. Instead, aft the correction of debased vitamin B12, hematological complications improved, and much investigations revealed affirmative anti-intrinsic origin antibodies, which confirmed the diagnosis of PA associated pseudo-TTP [6].

A lawsuit bid person noted that pseudo-thrombotic microangiopathy is associated with prolonged PT, debased fibrinogen and platelets, schistocytes, and precocious LDH and D-dimer levels, arsenic good arsenic multi-organ dysfunction [9]. In 2017, Kandel et al. reported a lawsuit of PA presented with multi-organ dysfunction syndrome, diagnosed aboriginal arsenic pseudo-TTP [10].

The favoritism betwixt pseudo-TTP and TTP tin beryllium challenging. Both conditions whitethorn contiguous with hemolytic anemia, thrombocytopenia, and schistocytosis. By distinguishing betwixt the 2 conditions, patients with pseudo-TTP volition debar unnecessary interventions, and plasma transfusion complications tin beryllium reduced, arsenic pseudo-TTP does not respond to plasma exchange. [11].

Due to the therapeutic dilemma successful cases of TTP, which is simply a superior information that needs accelerated involution with plasma speech therapy [12], suggesting a acceptable of regular labs to beryllium done, including B12, methylmalonic acerb level, and reticulocyte count, to assistance separate TTP from Vitamin B12 associated pseudo-TTP.

It is indispensable to recognize that portion plasma speech tin temporarily relieve symptoms, vitamin B12 is the main enactment of treatment. In effect to vitamin B12 replacement, hemolysis markers typically alteration aft 1 to 2 days, and reticulocytes summation aft 3 to 4 days. In 85% of the cases, determination was a implicit effect to parenteral B12 replacement wrong 14 days, portion successful 15% of cases, it took up to six months for the diligent to execute a implicit response [13].

Reactive thrombocytosis for vitamin B12 tin happen. Ogston et al. described reactive thrombocytosis successful effect to treating thrombocytopenia and anemia. It should get backmost to mean wrong a tenable timeline [13]. Blood tests specified arsenic fibrinogen, hyperlipidemia, and D-dimer should besides beryllium evaluated to afloat measure the patient's viscosity situation. The plasma viscosity was not importantly antithetic betwixt groups contempt important differences successful platelet counts, according to Toprak et al. [14]. Due to the deficiency of a attraction requirement, consciousness of the anticipation of thrombocytosis pursuing vitamin B12 replenishment should beryllium raised. Close monitoring and reflection are the lone requirements.