Posts Tagged ‘Vitamin B12’

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.


Folic acid levels and unicorn sightings

December 12, 2016

My schedule was a basic mistake

The day off I just didn’t take

But abnormals times three?

It just couldn’t be

What kind of sense does that make?

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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. 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, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.


I had a speaking engagement in Sioux City, when it got rescheduled to January I forgot to change my calendar. Thus I came in at 8:00AM to an empty schedule.  It didn’t stay empty long.

Most of my patients had respiratory problems, and most had coughs with runny noses and a tobacco problem. I enjoyed making the children smile with my yoyo tricks, but finding a toddler with not one but two infected ears made my morning.

Despite a leisurely start, morning patients didn’t finish till after the noon hour.

The cafeteria here does a good job. Reasonable prices, reasonably sized portions, and very decent cooking put it in the top 10% of hospital food services.

I don’t know that I helped the last patient of the afternoon, but as I wrapped up, I asked about her work. Though she gave me permission to write more, I will say I learned about secondary distance learning in Iowa, and may have found Bethany some work. In the long run, I suspect the networking will bring more value to our interaction than the medical care.

I sat down to my lab results queue. I found a case of a vaccine-preventable illness, and we’ll soon have an epidemic here, but the notification came in after the Health Department had closed for the day.  I’ll end up taking medication for a few days because of the exposure.  It goes with the territory, but as a self-employed physician, turning it into Worker’s Compensation makes no sense.

The next lab number just about knocked my socks off, a low folic acid level. Folic acid and Vitamin B12 work together to repair DNA, keep the marrow producing blood, and the nervous system from deteriorating.  They work together; an excess of one can hide a deficiency of the other; thus you can’t buy a folic acid pill more than 400 micrograms without a prescription.  But 15 years ago the FDA mandated folic acid supplementation in our flour supply.  The deficiency of that vitamin, never common to start with, just about evaporated.  Up to now I’ve not seen more than a half-dozen cases.

So finding one really put the music into the end of the day. I called the patient, discussed the problem, fiddled with the computer, sent the prescription, and opened the next set of lab results.

My jaw dropped. Could it be?  Two folic acid deficiencies in a row?  And there it was.  Lower limit of normal 7.1.  Patient’s level 3.9.  Yep.  What a rush!

Another enthusiastic call to a patient, another prescription sent at the speed of light to the pharmacy. And on to another lab result.

Wait a minute.

Three folic acid deficiencies in a row defy credibility.

If you see a unicorn, you get bragging rights, and if you see two in an afternoon, you get big bragging rights. But if you see three, you need to get your eyes checked.  Tomorrow I’ll have a talk with the lab.

Discharge summaries

January 30, 2016

I can’t believe how the time flies

We’ve already said our goodbyes

I got into the groove

And now we must move

And drive east into the sunrise.

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. I just finished two months in western Nebraska. Any patient information has been included with permission.


Friday dawned clear, cool and bright. We got up early for the finishing touches on moving out.

The townhome the agency rented for us surpassed all expectations with cathedral ceilings, hardwood floors, good construction, comfortable mattress, serviceable equipment, and a killer view. I moved stuff out the front door to the walk by the car while Bethany packed. We left notes for the landlord and the neighbor.

We stopped at the hospital. I had forgotten one bit of documentation when I discharged a hospital patient on Wednesday.

The discharge summary recounts what happened during a patient’s hospital stay. When I finished residency, I would go through the whole chart from the first day, giving lab values, reading x-ray and consultation reports, and recounting vital signs in detail.  Later I learned to dictate my hospital notes so I could do the discharge summary from them.  Later still, I changed my model to answer the question: What does the next doctor need to know?

In the 80’s I deliberately waited two weeks after discharge to do the summary, because vitamin B12 levels and thyroid functions could take that long to come back. Paper charts in those days dominated the doctors’ lounge; you couldn’t get your coffee without being reminded you needed to clean up your paperwork.  And you could see everybody else’s backlogs.  I’d clean things out once or twice a month.

By the last half of the first decade of this century I had started to dictate the discharge summary at time of discharge, so I could have a copy when the patient came to see me a week later.

Some attending physicians pay residents, Physician Assistants, or Nurse Practitioners to do the discharge summaries.

Now the hospital’s Electronic Medical Record puts in all the lab values, discharge medications, and x-ray reports. I summarized 11 days of hospital care with 4 sentences typed into the middle of the document under the heading Hospital Course.  The next doc will have to scan through pages of note bloat to get to the part that he or she will need to know.

With all the documentation done, we drove the loaded car through town to a chain diner.

Over a luxury breakfast out, we talked about how fast the time had gone. It hardly seems two months since we arrived.

I found 4 new cases of Parkinson’s disease, 2 new cases of hypothyroidism, and 1 case of vitamin B12 deficiency. I referred people with, variously, a hernia, a hot gallbladder, and a bad appendix to the surgeon.

When major trauma cases came in I kept things moving in the outpatient clinic.

On the weekends when we didn’t go to Denver, visit a niece in Wyoming, or go shopping at Cabela’s, I made rounds in the hospital.

We went to the movies three times; the tickets cost less than half of what we usually pay.

We ate at every Chinese restaurant in town at least once. We saw eagles, deer, jackrabbits, migrating ducks and geese.

After breakfast, we started east down the highway, under clear blue skies with the wind at our back.

Short lines of communication, unusual prescriptions, and vitamin B12 deficiency

May 6, 2015

Foxes, itches, triumph, and hunter: on the cusp of leaving Nome

April 1, 2015

On the med list I’m pulling a switch
‘Cause my patient came down with an itch
Now they’re getting the sleep
That’s restful and deep
And for trazodone I found the right niche

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, travelled and worked out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m back to Nome from temporary detail to Brevig Mission.

I took care of a patient with a very bad diagnosis and a very bad itch. I will leave it up to the specialists to try to change the course of the disease, here in Nome I will try to relieve suffering. Because itch in the context of unrelenting pain constitutes torture. We looked over the med list.

Me: Aren’t you allergic to codeine?

Patient: Yes, it makes me itch, real bad. Same with the hydrocodone.

Me: Stop picking at yourself. Why do you take the oxycodone?

Patient: Beats me. Doesn’t work. That’s why I finished ’em early.

Me: If they don’t work, why do you take it?


Me: Maybe oxycodone is making you itch. Let’s try stopping it.

Patient: But how am I going to sleep?

Me: How are you sleeping now?

Patient: I’m not. Those pills don’t work.

Me: Maybe we should stop them.


Me: How about if I give you a sleeping pill to help you sleep and you come back next week. How about trazodone?

It took some explaining, but the patient came in, looking fresh and happy and focusing a lot better, having slept well 4 nights in a row, and now having much less pain. Because (everyone knows) that good sleep helps a person deal with pain.

And another demonstration of the principle of ABCD (Always Blame the Cottonpickin’ Drug).


I can post this about the young man because I got permission from him and his mother and because everything is on Facebook. Well on the way to being a hunting legend at age 14, he got his first polar bear at age 11, same year he got his first bowhead whale. He has lost track of the number of walruses he’s gotten so far this year. I still won’t publish his name or what he came in for.


I stepped into my cubicle about 10 in the morning and saw a red fox run past.

Foxes hunt at night, any abroad by day raises suspicions of rabies. At home, if I see raccoon, skunk, or fox outside of dusk, dawn, and night, I will seek a weapon to dispatch the animal. In Barrow, we assumed rabies in all arctic foxes.

The furry red animal ran along the north side of the building, around to the west. I said, loudly, “There goes the fox!” and strode briskly to the other end of the clinic to try to get another look; I worried it might head to town. I didn’t see it again, and decided it dens either under the hospital or in the maze of construction dross nearby.


The first patient of the day felt really, really good after the vitamin B12 shot yesterday. Best in years; better sober after that shot than drunk.

Which made my day.


I leave tomorrow after an abbreviated afternoon clinic. Staffers have come in to wish me well. I got a great going-away card, a very trendy tote bag, and a pair of hand knit socks. Along with the story of the wool (starting with the sheep) and the WWI-era sock knitting machine.

Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

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.

I enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

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.

On B12, fatigue, malaise, and clinical experience.

June 30, 2010

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.