Posts Tagged ‘homocysteine’

It’s not pernicious if the patient live

February 28, 2017

To test, I wouldn’t think twice

The abnormal I find ever so nice

And if that’s what they’ve got

I just treat with a shot

Still cheap at thirty times the price.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

About twenty years ago I stopped a neurologist in the hospital parking lot for a “curbside consult,” a long-standing tradition. These brief interactions transmit a lot of information.  In the days before the Internet, I realized I needed to know more about vitamin B12 deficiency than I could get from books or journals.

In medical school they taught us not to check B12 levels on anyone under 40. The characteristic findings on the blood smear, they said, with enlarged red cells, anemia, and white cells with too many nuclei, would show before anything neurologic; thus we shouldn’t run the expensive test if the person had a normal blood count.

Time has a way of slaughtering such dogma. I found myself in the middle of a diagnostic series of B12 deficiencies, the most recent at that time a 36-year-old with the classic blood findings. I modified my age criteria and, sure enough, found a very low B12 level, helping to account for symptoms of what otherwise looked like depression with clumsiness.

Before I collared the neurologist, I’d sat down to talk with the hematologist. In the course of 5 minutes I realized he didn’t know much more about the topic than I did.  Approaching the neurologist turned out well.

He said that anything under the lower limit of normal (has gone back and forth between 199 and 287 and has now held steady at 211) clearly shows a problem. Any B12 level over 400 can’t take the blame for a problem.  But the gray zone between 211 and 400 demands judgment.  Anyone with symptoms at or past age 65, he told me, should be treated.  At 35 cents a dose, you can’t justify the expense of further testing.

Since I started this blog in 2010, the price of vitamin B12 has gone from $.35 to $9.00 per dose, justifying further testing in the borderline area. Now when I have suspicions, I check levels of methylmalonic acid and homocysteine, two toxic byproducts that build up in the blood in the absence of adequate vitamin B12 and/or folic acid.

Just about anything neurologic, whether subjective or objective, prompts me to investigate. If someone complains of fatigue, numbness, weakness, depression, erectile dysfunction or trouble concentrating, I go looking.  And the same if the blood smear shows enlarged red cells (an increased MCV or mean corpuscular volume), or even a broadened range of red cell sizes (RDW, or red cell distribution width).

Last week I found 4 new cases of vitamin B12 deficiency on one morning, making me ecstatic to the point of silly. The next day I got elevated homocysteine levels  back on two other patients with borderline B12 levels.

We used to call vitamin B12 deficiency pernicious anemia because the patient always died, and I grew to love the diagnosis because as a frontline doctor I could save the patient’s life for 2 cents a day. Now it costs 30 cents a day.  It still makes me happy.

 

Limits of normal

October 27, 2012

The neurologist I saw face to face.

We discussed a clinical case.

Involving depression

And a bad drinking session

And an interesting diagnostic chase.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The lower limit of normal for Vitamin B12 has moved from 200 during my residency in the 80’s to a high of 287 in the mid ‘90s and has hovered at a more or less constant 220 ever since.  The lab report always comes with a  caveat: if the level is over 400, replacement rarely benefits the patient, but between 220 and 400, some people will benefit from B12 shots.

In the hospital parking lot a couple of decades ago, I stopped a neurologist for advice in generating an algorithm to deal with B12 deficiency.

In med school and residency, they taught us not to test anyone under 40, and not to test if the blood count (CBC) showed normal looking white cells without extra lobes in their nuclei, and normal, rather than large, red cells. 

By the time I’d been out of postgraduate training for ten years, I recognized I’d gotten a poor substitute for truth.  I’d tried pumping wisdom out of a hematologist (blood specialist) but quickly realized he didn’t know more than me. 

Then I spotted the neurologist in the parking lot while I puzzled over a patient, age 38, with numbness and a normal CBC but a B12 level less than 150.

Curbside consultation, the discussion of cases with colleagues on an informal basis, remains a vital institution even in the digital age, and comes with its own etiquette.

The neurologist smiled, and in less than 30 seconds slaughtered enough sacred cows for a Texas-sized barbecue.

Forget the CBC, concentrate on the symptoms.  In a patient over age 70 with symptoms and a level under 400, treat with injectable B12, don’t do any follow-up testing unless they deteriorate neurologically.  If you really, really want to know if B12 lies at the root of the problem, you can do further testing (methylmalonic acid and homocysteine levels) if you want, but at the rate of $3.50 per year of treatment, extra testing rarely justifies its cost.

Since then I learned that alcohol interferes with a body’s ability to utilize B12, thus most alcoholics have big red blood cells and levels of B12 over 3000.

B12 deficiency, formerly known as pernicious anemia because before B12’s discovery the patient always died, remains one of my favorite diagnoses.  I get to save the patient’s life for less than a penny a day, with an injection given once a month.

Yesterday on rounds I sat in a patient’s room and leafed through the lab work.  With very large red cells on the CBC, and some vague neurologic symptoms, I had ordered a B12 level two days before.  I suppressed a whoop of delight when I found a 188.  “We can help you,” I said.

One floor down, I talked with an alcoholic about a marginal B12 level, 244, and recommended starting B12 shots.  Your depression won’t improve, I said, if you don’t have enough B12, and it’s hard to control your drinking when you’re so depressed.

Then I walked, grinning, down the hallway.  My favorite diagnosis, twice in a morning.

Allergies, joint pains, and nerves

April 28, 2010

If symptoms come in the spring

And don’t have a classical ring

    Allergies?  Please,

    You don’t have to sneeze

To enjoy the Hismanal zing

I won’t say when this happened except it coincided with call.  I got a call from one of the ER docs.  We have a sound working relationship.

A person, not my patient, came to the Emergency Room with some unusual neurologic symptoms, despite previous investigation.  The ER doctor didn’t know how much investigation, but before reinventing the wheel, wanted to know if I could access the medical records.  And strangely, I could, despite the late hour.

With a normal MRI, neurologic consultation failed to reach a diagnosis. 

“Yeah,” I said, “They got all the scans, but it doesn’t look like they did much in the way of chemistries.  Needs a B12 and a folate and a vitamin D, that’s for sure.  Nerve conduction studies are OK.  Spinal tap was normal, ok, yeah, MS is completely ruled out.  Oh, wait a minute, we’ve got a normal homocysteine and methylmalonic acid.  And here’s the B12, it’s 396, kind of borderline, but if the methylmalonic acid level is normal, the B12 is fine.”

(I didn’t mean to show off, my colleague understood me.  Without enough vitamin B12 or folic acid, two toxic products build up in the blood, methymalonic acid and homocysteine; a very savvy neurologist had investigated both chemicals, anticipating that the B12 might come back as marginal.)

“Now, hold on,” I said, coming to another page, “Looks like the symptoms were identical this year, last year, and the year before.  Patient’s been worked up three times already.  Always in the spring.”

We indulged in a thought pause.

“You know,” I said, “A while ago I knew a patient, came in every spring for seven years looking for all the world like rheumatoid arthritis.  All the blood work came out negative.  I tried seven different anti inflammatory drugs that didn’t help, and in the eighth year I gave a prescription for Hismanal [an antihistamine no longer on the market], figuring that if it happened in the spring it was probably allergic.  I got a call back a few hours later saying the pain had completely stopped.”

“Well,” the voice at the other end said, “That’s a thought.”

We agreed that the patient deserved a vitamin D level and a trial of an antihistamine.

If all diseases were textbook, we wouldn’t need doctors so much as textbooks.  In the real world, the five percent of the population who fall outside the normal parameters present eighty percent of the challenges.  Being a doctor requires being able to think outside the box while respecting the contents. 

I talked with that same doctor this evening.  We discussed a patient in the ER.  I broke the news about my coming career move, and my plan eventually to work with the Community Health Center.  When we finished talking I got the impression the other doctor was looking forward to working with me again.

I have 23 days and three call nights left. I talk with recruiters a couple of times a day, resisting taking jobs longer than two months.