On B12, fatigue, malaise, and clinical experience.

For patients feeling malaise,

B12 is a blood test that pays.

      Don’t look at the blood cells

      Just check on the B12

And treatment’s a penny a day.

A patient came in with vague symptoms a week ago and gave me permission to give some information.  Having had a gastric bypass a number of years ago, about a month ago the patient noted fatigue and malaise, just an overall lousy feeling, gradually getting worse.  I ordered the usual panel of tests: CBC, sed rate or ESR, Chemistry 14, B12, folic acid, thyroid stimulating hormone or TSH, mono spot, 25 OH vitamin D, and for men, a testosterone level. 

Our reference lab says that levels of 20 to 30 are vitamin D insufficiency, above 30 is normal(some literature supports 40).  This patient’s level came back at 8. 

We didn’t learn much about Vitamin B12 in med school.  It’s important, we were told, because of pernicious anemia, but chances are you won’t see any problems with it.  And don’t even bother to check if the patient is under 40 and has normally shaped red blood cells.

In residency I diagnosed an elderly patient who had tingling of the hands and feet with B12 deficiency; her level was 199 and the lower limit of normal was 200.   She felt much better the day after the first injection, some of the other docs felt because of the placebo effect.

Years later, in private practice, and I saw a 38-year old who didn’t feel good with large red blood cells.  Her B12 level was low, and the patient felt much better after the first injection.  Over the next three months I lowered the age bar on the basis of experience, and when the 19-year-old artist came up with a lower level, I abandoned age as a decider.  The youngest one I’ve found so far was 11.

In the days before online physician communities, I sought out the hematologist,   someone who should know more than me.  When it came to B12, he didn’t. 

I’d been  pondering for a month, getting what I could from books, when I ran into a neurologist in the hospital parking lot.  No age limit, he said, and don’t both with further testing after a low level.  If they give their own shot, it costs $3.50 for ten months treatment.  And if the person is over the age of 60, has symptoms and a level under 400, treat them.

Which sounded a little radical, but within three months the reference lab started sticking on a caveat that said 10% of those with a level under 400 benefit from injections.

A patient, who did not do well, came to the hospital with a B12 level of “undetectable.”  The red and white blood cells were perfectly normal.  An extreme case which I will never forget; a CBC is a lousy way to decide to check for the problem.

B12 only comes from animals (seaweed is close enough).  Strict vegetarians eventually have B12 problems.  Most people who lack the vitamin eat plenty of meat, but have lost their ability to absorb it.  And with the growing number of people on acid reducers (think purple pills), more and more people can’t absorb B12 at all.

The patient with the gastric bypass has fingertip tingling and a level of 357.  If not for the previous medical history, and my previous clinical experience, I’d be willing to give her vitamin B12 pills in large doses with a recheck of the level in 6 months.

Ninety percent of the patients I started on B12 injections in the last 20 years gave their own injections; I never wanted to have a reputation of being a “shot doctor.”  Nor did I want my motivations questioned.

I have found three cases of B12 deficiency and three cases of B12 insufficiency in my four weeks in Barrow.

Tags: acid reducer, B12, fatigue and malaise, red blood cell indices, Vitamin B12, vitamin deficiency