Symptoms
Why did Suzanne present with lower extremity paresthesias?
Impact to myelinated nerves in the peripheral nerves system.
What is the MCV range to classify microcytic, normocytic, and macrocytic anemias?
Microcytic -- less than 80 fL
Normocytic -- 80-100 fL
Macrocytic -- greater than 100 fL
Suzanne's *** on exam supports anemia with cardiac compensation to delivery O2 to tissues
tachycardia (HR 108)
Normal bilirubin rules out what pathological process in other anemias?
Hemolytic anemias (intravascular and extravascular)
What part of Suzanne's history supports an autoimmune etiology for her deficient vitamin B12 deficiency?
Follow up: what medication is she taking to manage this?
History of Hashimotos, diagnosed at 27
Resultant hypothyroidism (treated with daily Levothyroxine PO 100 mcg/daily)
Tachycardia can be classified as over *** bpm
100
Suzanne's tachycardia on her physical exam was secondary to...
Tissue hypoxia due to anemia. Resulting in increased cardiac output and rate to try and compensate
What delivery method of treatment is required with patients with pernicious anemia?
Intramuscular (IM)
Lifelong treatment for patients with confirmed pernicious anemia starts with an intramuscular (IM) injection of 1000 micrograms of B12 (hydroxocobalamin in Europe or cyanocobalamin in the United States) administered daily or every other day for 1 to 2 weeks, followed by weekly injections for 1 to 2 months, then a monthly injection (cyanocobalamin) or every 2 to 3 months (hydroxocobalamin)
The subacute combined degeneration seen in later stages of vitamin B12 deficiency is due to ...
Increased levels of methylmalonic acid
Folate supplementation will ONLY help what one symptom of vitamin B12 deficiency
Anemia
** Will not correct neurological symptoms - will exacerbate neurological symptoms
Elevated levels of homocysteine are additive to the cardiac stress seen in vitamin B12 deficiency --> resulting in murmurs, tachycardia, irregular heartbeat and heart failure. Why is homocysteine additive to this stress?
Homocysteine causes fatty deposition in blood vessels which can collect in blood vessels around the heart
In prolonged vitamin B12 deficiency, parenthesis will worsen due to ...
subacute degeneration of the dorsal column and lateral column of the corticospinal tracts
Where is vitamin B12 stored, and approximately how long of a deficit is needed for symptoms to present?
Liver
Takes years of a sustained deficit for symptoms to arise if secondary to decreased intake. Samatha's case secondary to malabsorption specifically
What areas of the stomach did Suzanne have atrophy?
Corpus and anatral
What physical exam finding in Suzanne's case was suggestive of severe loss of position sense due to the vitamin deficiency?
Positive Romberg test
Elevated methylamonic acid eliminates what other vitamin deficiency that also presents with hyper-segmented neutrophils?
Folate deficiency - will only see elevated homocysteine