Clinical Communications: Adult| Volume 64, ISSUE 2, P217-219, February 2023

Primary Neurologic Symptoms: Have You Considered Pernicious Anemia?



      Vitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12.

      Case Report

      A 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms.

      Why Should an Emergency Physician Be Aware of This?

      Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.


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        • Lieberman M
        • Peet A
        Marks’ Basic Medical Biochemistry: A Clinical Approach.
        5th edn. Wolters Kluwer, 2018
        • Osborne D
        • Sobczyńska-Malefora A.
        Autoimmune mechanisms in pernicious anaemia & thyroid disease.
        Autoimmun Rev. 2015; 14: 763-768
        • Andres E
        • Serraj K.
        Optimal management of pernicious anemia.
        J Blood Med. 2012; 3: 97-103
        • Rodriguez NM
        • Shackelford K.
        Pernicious Anemia.
        StatPearls Publishing, 2022 (Accessed May 27, 2022)
        • Gill L
        • Zarbo A
        • Isedeh P
        • Jacobsen G
        • Lim HW
        • Hamzavi I.
        Comorbid autoimmune diseases in patients with vitiligo: a cross-sectional study.
        J Am Acad Dermatol. 2016; 74: 295-302
        • Sheth VM
        • Guo Y
        • Qureshi AA.
        Comorbidities associated with vitiligo: a ten-year retrospective study.
        Dermatology. 2013; 227: 311-315
        • Akay B
        • Bozkir M
        • Anadolu Y
        • Gullu S.
        Epidemiology of vitiligo, associated autoimmune diseases and audiological abnormalities: Ankara study of 80 patients in Turkey: Clinical, laboratory and genetic aspects of vitiligo.
        J Eur Acad Dermatol Venereol. 2010; 24: 1144-1150
        • Sawicki J
        • Siddha S
        • Rosen C.
        Vitiligo and associated autoimmune disease: retrospective review of 300 patients.
        J Cutan Med Surg. 2012; 16: 261-266
        • Gupta Y
        • Ammini A
        Vitiligo, hypothyroidism and cardiomyopathy.
        Indian J Endocr Metab. 2012; 16: 463
        • Silajdzija E
        • Bliddal S
        • Borgwardt L
        • et al.
        Severe weight loss in a hypothyroid patient as an acute presentation of autoimmune polyglandular syndrome type II.
        Hormones. 2022; 21: 317-322
        • Egli F
        • Walter R.
        Vitiligo and pernicious anemia.
        N Engl J Med. 2004; 350: 2698
        • Jain KK
        • Malhotra HS
        • Garg RK
        • Gupta PK
        • Roy B
        • Gupta RK.
        Prevalence of MR imaging abnormalities in vitamin B12 deficiency patients presenting with clinical features of subacute combined degeneration of the spinal cord.
        J Neurol Sci. 2014; 342: 162-166
        • Haines DE
        • Willis MA
        • Lambert HW.
        Neuroanatomy Atlas in Clinical Context: Structures, Sections, Systems, and Syndromes.
        10th edn. Wolters Kluwer, 2019
        • Tutaj A
        • Tomczykiewicz K
        • Zaleska B
        • Janda R.
        Neurologic signs in Addison-Biermer disease (report of 3 cases)).
        Neurol Neurochir Pol. 1997; 31: 35-41
        • Shipton MJ
        • Thachil J.
        Vitamin B 12 deficiency – A 21st century perspective.
        Clin Med. 2015; 15: 145-150