Why Vitamin B12 Deficiency Should be on your Radar Screen

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<strong>Vitamin</strong> <strong>B12</strong> <strong>Deficiency</strong> methylmalonic acid (MMA) and homocysteine (Hcy) levels. Results of Confirmatory Testing Both her MMA and Hcy levels are elevated. Her MMA is greater than 0.5 micromoles per liter (μmol/L), and her Hcy is greater than 17 μmol/L, confirming your suspicion that this patient has a vitamin <strong>B12</strong> deficiency. You decide to investigate the cause of her vitamin <strong>B12</strong> deficiency. Although she denies a history of pernicious anemia in her family and she has had no previous indication of autoimmune diseases, you order an antiintrinsic factor (IF) antibody test that confirms the presence of pernicious anemia. Management You explain that with the diagnosis of pernicious anemia she will have to continue vitamin <strong>B12</strong> therapy for the remainder of her life, and you make a note on her chart to assess her compliance at each visit. You also advise her to inform her family of the diagnosis <strong>be</strong>cause there is possibly a genetic component. You start her on vitamin <strong>B12</strong> intramuscular (IM) injections. She gets IM cyanocobalamin 1,000 micrograms (µg) two times per week for 2 weeks and then switches to oral vitamin <strong>B12</strong> 1,000 µg daily thereafter. Almost immediately after the initiation of injections, she reports improved concentration. Within 2 weeks, she notes less fatigue and normal appetite. Case Study 2 Presentation An 85-year-old female with a 15-year history of Parkinson disease (PD) is seen for her regularly scheduled follow-up with her neurologist. History On review of systems, family mem<strong>be</strong>rs report that she has <strong>be</strong>come more withdrawn and irritable during the last 9
<strong>Vitamin</strong> <strong>B12</strong> <strong>Deficiency</strong> 6 months. They also report that activities she previously accomplished without difficulty, such as going to church, seem to exhaust her. She acknowledges this symptom, stating that she feels her stamina is much lower than at the time of the last visit. She and her family do not report an appreciable difference in or worsening of her motor symptoms, but they do report that she has had some hallucinations in the form of seeing farm animals periodically in her room. Her current medications include Stalevo(carbidopa, levodopa, and entacapone), amantadine, Evista ® (raloxifene hydrochloride), Effexor ® XL (venlafaxine hydrochloride), Detrol ® LA (tolterodine tartrate), Mirapex ® (pramipexole dihydrochloride), and Ambien ® (zolpidem tartrate). She denies any obsessive or compulsive <strong>be</strong>haviors or any recent trauma, but she does admit having a decreased appetite and eating little or no meat. Her family descri<strong>be</strong>s her nutritional intake as poor, stating that she is just getting by on “tea and toast”. Her social history reveals a widowed elderly woman who lives with her son and daughter-in-law. She had lived independently until 5 years ago, when completing her activities of daily living (ADLs) <strong>be</strong>came too difficult. She currently has a home health nurse visit once a day to assist with ADLs and noontime medications while her family is at work. Physical Examination A general examination reveals a frail, thin female with skin irritation and slight amount of saliva evident at the right corner of her mouth (the side where her PD symptoms are more pronounced). She has slight puffiness but no pitting of her ankles bilaterally. A neurological examination reveals that she is alert and oriented to person, place, and year. She remem<strong>be</strong>rs 3 out of 3 items, but can recall only one of three items 3 minutes later. She has definite facial masking and a decreased blink rate. Cranial nerve examination reveals moderate hypophonia (low voice volume) and an intermittent tremor. She is moderately stooped with a slight tilt to the right, and she has difficulty rising from a 10 Protein intake among patients with Parkinson disease (PD) might interfere with levodopa’s clinical <strong>be</strong>nefit. Thus, PD patients might inadvertently increase their risk of vitamin B 12 deficiency by avoiding meat, the dietary source of vitamin <strong>B12</strong>.
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Why Vitamin B12 Deficiency Should be on your Radar Screen

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