Posts Tagged ‘pernicious anemia’

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.

A three-pack of vitamin deficiencies

February 1, 2011

A folic acid deficiency,

With a vitamin B12 insufficiency

     Gave fatigue and malaise

     And without the sun’s rays

Led to calcium metabolism inefficiency

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

Vitamin D deficiency runs rampant here because Barrow doesn’t receive any useable sunlight ten months a year.  UV irradiation raises the level in milk and dairy products, but not enough for most people.  Missaghak, fermented seal oil, has a lot, but for various reasons the people here don’t consume as much as they used to.

Without adequate vitamin D, a body can’t absorb or utilize calcium properly, and mobilizes the mineral from bone.  While the bones weaken, the layers of bone that have lost matrix start to swell, and the vitamin D deficient patient, in addition to feeling lousy, hurts all over. 

Doctors debate about vitamin D deficiency; some assert that it garners too much attention, but even the worst naysayer would agree a level in the single digits merits treatment.

Vitamin B12 comes only from animals or things resembling animals; human beings don’t make it and have to ingest it.  Most people in the US get enough B12 from eating meat, eggs, and milk.  Strict vegetarians (such as Hindus) in third world countries get enough insect contamination in their grains to fulfill their B12 needs.

A strict vegetarian, who uses no meat, fish, poultry, leather, honey, eggs, milk, or soap exists on a higher moral plane than the rest of us, but has, at most, a ten-year life expectancy.  Vitamin B12 deficiency would start showing itself at five years, and would progress to an ugly death five years later.

As people age, they can lose their ability to absorb vitamin B12, which leads to deficiency.

As a child, I heard the phrase pernicious anemia but I didn’t know what it meant; at the time the term circulated enough that most people had heard it.  It warranted the name pernicious because the patient always died.  With the discovery of vitamin B12, and its cofactor folic acid, the problem found a treatment.  Most people in the twenty-first century have never heard of pernicious anemia.

Folic acid works with vitamin B12 to repair nerve cells and blood-forming tissue.  An excess of folic acid can cover early deficiency of vitamin B12, allowing irreversible neurologic damage without any sign of anemia.  Thus, by law, over-the-counter vitamins can contain no more than 400 micrograms of folic acid per pill.

The first sign of folic acid or B12 deficiency is just plain not feeling good.

Folic acid deficiency happens rarely; the vitamin occurs widely in nature, and people don’t lose their ability to absorb it.  Though I check often, I have seen fewer than ten cases in the last three decades.

I got to sit down with a patient (who gave me permission to write this information) and say, “I can help you, I can make you feel better.  You have three vitamin deficiencies.”

More than you wanted to know about pernicious anemia, vitamin B12, folic acid, and rheumatoid arthritis

July 9, 2010

 

I think meat is nutritious

You might even call it delicious.

     Twelfth vitamin B

     Necessary, you see;

To preventing anemia pernicious

Weather in Barrow today turned warmer on the land and cooler over the ocean.  The sea ice reappeared a hundred yards from shore and covered the ocean out to the horizon.

For some reason there’s a lot of rheumatic disease on the North Slope.

Rheumatoid arthritis is not the same as wear and tear arthritis.  If the immune system is the army and police of the body, rheumatoid arthritis happens when the defenders mistake the civilians for the enemy.  People with rheumatoid arthritis do not feel well, they feel sick all the time, they have morning stiffness and if they sit too long they stiffen up, mostly in the small joints of the hands.  The disease waxes and wanes but until recently followed a relentless progressive course.

Methotrexate, a cancer chemotherapy agent, finds uses in small, weekly doses for those with RA.  Effective, to be certain, but it carries risks.  Hard on the liver, it interacts with a lot of drugs.  We usually prescribe methotrexate patients a milligram of folic acid a day to buffer some of the side effects, and stringently warn people not to use alcohol.

Over the counter vitamins by law can contain no more than 400 micrograms of folic acid a day for good reason.

Pernicious anemia was called pernicious because the patient got always died.  In the era of vitamin discovery, ground desiccated pig stomach (“hog maw”) was found to halt the progression of pernicious anemia.  Eventually, research showed that pernicious anemia resulted from a lack of vitamin B12, which only comes from animals.

Vitamin B12 works in concert with folic acid in several critical steps of blood manufacture and nerve repair.  Adequate doses of folic acid can mask a deficiency of vitamin B12 in the blood while the nervous system deteriorates irreversibly.

I‘ve seen a few cases of advanced B12 deficiency and they weren’t pretty.  Once B12 injections were started the progression stopped but every single one was left with permanent neurologic damage, some looking like multiple sclerosis and some looking like Alzheimer’s.

So when a patient comes to me already on folic acid for whatever reason (such as methotrexate therapy for rheumatoid arthritis, or replacement therapy for folic acid deficiency) I have an excuse to check the vitamin B12 level.  And few things give me as much pleasure as diagnosing B12 deficiency; I can save the patient’s life for less than two cents a day.

This morning I sat down to talk with a rheumatoid arthritis patient (who gave me permission to write this) about not only vitamin B12 deficiency but vitamin D deficiency as well.  

The first symptom of low vitamin B12 is a lack of energy, which can look for all the world like depression, as can hypothyroidism, autoimmune diseases, hepatitis C, vitamin D deficiency, electrolyte imbalance, drug side effects, testosterone deficiency and anemia.  Later on comes numbness, tingling, loss of coordination, and memory loss.