Life-threatening Pseudo-thrombotic Microangiopathy Caused by Severe Vitamin B12 Deficiency

Ziad Abuhelwa^1, , Talal Khan², Rana Daas³, Sami Ghazaleh¹ and Ragheb Assaly¹

¹Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio 43606

²Department of Hemato-Oncology, University of Toledo College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio 43606

³University of Toledo College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio 43606

Cite this paper

Ziad Abuhelwa, Talal Khan, Rana Daas, Sami Ghazaleh and Ragheb Assaly. Life-threatening Pseudo-thrombotic Microangiopathy Caused by Severe Vitamin B12 Deficiency. American Journal of Medical Case Reports. 2021; 9(11):532-534. doi: 10.12691/AJMCR-9-11-3

Abstract

Vitamin B12 deficiency is a common cause of macrocytic anemia. Life-threatening hematologic complications including immune and non-immune hemolytic anemia are present in about 10% of the cases. Pseudo-thrombotic microangiopathy is an extremely rare presentation found in around 2.5% of patients with vitamin B12 deficiency. We present a case of a 70-year-old male patient who presented with progressive fatigue and syncope. He was found to severe macrocytic anemia with hemoglobin of 4.1 g/dL. Further workup showed very low serum vitamin B12 level at 22 pg/mL (normal 180-914), methylmalonic acid of 93.23 umol/L (normal 0-0.4) and homocysteine of 93 umol/L (normal 4-12). Anti-parietal cell and intrinsic factor blocking antibodies were positive. He was noted as well to have thrombocytopenia, low haptoglobin, increased lactate dehydrogenase and increased serum creatinine. Peripheral blood smear showed schistocytes, hyper-segmented neutrophils, and marked dimorphic anemia. His presentation was concerning for thrombotic thrombocytopenic purpura; however, PLASMIC score was intermediate. He was monitored in the intensive care unit. He received supportive treatment with intravenous hydration and packed red blood cells transfusion. He was started on daily intramuscular cyanocobalamin supplements. Significant improvement in his symptoms with near normalization of complete blood count after one month of treatment was noted. His condition improved without the need for plasmapheresis.

Keywords

hemolysis, Vitamin B12, anemia, autoimmunity

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

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