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6. 6 B12 Deficiency Britni Hebert, PGY 2 02.10.2010

7. 7 SUMMARY ❖ B12 in the normal host ❖ B12 in the abnormal host ❖ Presentation ❖ Diagnosis ❖ Treatment

8. 8 Normal B12 Metabolism ❖ Dietary Intake ❖ Gastric Acid and Pepsin ❖ Pancreatic Proteases ❖ Intrinsic Factor ❖ Ileal receptors

9. 9 Normal B12 Metabolism

10. 10 Normal B12 Metabolism

11. 11 Abnormal B12 Metabolism

12. 12 Presentation ❖ Alcoholics, Elderly, Vegans ❖ H/o Gastric Bypass, Elderly ❖ Neurologic complaint ❖ Blood Dyscrasias ❖ Anemia (elevated MCV in only 36%!) ❖ Macrocytosis, Ovalocytes ❖ PANCYTOPENIA ❖ Hypersegmented neutrophils

13. 13 Heme Path

14. 14 How to diagnose (1) Cobalamin level (1) > 300 (2) 200-300 (3) < 200 (2) Methylmalonic Acid, Homocysteine

15. 15 How to Treat ❖ Oral ❖ Nasal ❖ Sublingual ❖ Parenteral

16. 16 What else is there? ❖T❖Treatable causes should be searched out.

17. 17 1 slide on pernicious anemia ❖ Common ❖ Anti-IF AB ❖ Atrophic gastritis ❖ Schilling Test

18. 18 Back to our patient ❖ Marked Hemolysis ❖ Acute presentation

19. 19 References ❖ Dtsch Med Wochenschr. 2007 Jul 29;132(27):1469-74. [Pancytopenia and hemolysis--diagnosis, differential diagnosis and therapy of pernicious anemia] [Article in German] Meier N, Lipp E, Solenthaler M.Meier NLipp ESolenthaler M ❖ Physiology of B12, Up To Date ❖ Clinical Manifestations of B12 Deficiency, Up To Date ❖ Diagnosis and Treatment of B12 Deficiency, Up To Date