Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review

Yazan Fahmawi,1 Yesica Campos,1 Moh’d Khushman,2 Omar Alkharabsheh,2 Ashish Manne,2 Haseeb Zubair,2 Saadia Haleema,3 Jacek Polski,3 Sabrina Bessette11Department of Internal Medicine, University of South Alabama, Mobile, AL, USA; 2Department of Hematology-Oncology, Mitchell Cancer Institute...

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Autores principales:	Fahmawi Y, Campos Y, Khushman M, Alkharabsheh O, Manne A, Zubair H, Haleema S, Polski J, Bessette S
Formato:	article
Lenguaje:	EN
Publicado:	Dove Medical Press 2019
Materias:	Vitamin B12 deficiency Pseudo-thrombotic microangiopathy Schistocytes Therapeutics. Pharmacology RM1-950
Acceso en línea:	https://doaj.org/article/621a085badb4438a9c69b2ee4a49f6e6
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spelling	oai:doaj.org-article:621a085badb4438a9c69b2ee4a49f6e62021-12-02T05:32:05ZVitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review1179-1438https://doaj.org/article/621a085badb4438a9c69b2ee4a49f6e62019-08-01T00:00:00Zhttps://www.dovepress.com/vitamin-b12-deficiency-presenting-as-pseudo-thrombotic-microangiopathy-peer-reviewed-article-CPAAhttps://doaj.org/toc/1179-1438Yazan Fahmawi,1 Yesica Campos,1 Moh’d Khushman,2 Omar Alkharabsheh,2 Ashish Manne,2 Haseeb Zubair,2 Saadia Haleema,3 Jacek Polski,3 Sabrina Bessette11Department of Internal Medicine, University of South Alabama, Mobile, AL, USA; 2Department of Hematology-Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA; 3Department of Pathology, University of South Alabama, Mobile, AL, USACorrespondence: Yazan FahmawiDepartment of Internal Medicine, University of South Alabama, 2451 USA Medical Center Drive, Mobile, AL 36617, USATel +1 251 471 7891Fax +1 251 470 1652Email yfahmawi@health.southalabama.eduAbstract: Pseudo-thrombotic microangiopathy (pseudo-TMA) is a recognized, yet uncommon, clinical presentation of vitamin B12 deficiency. Patients with pseudo-TMA present with microangiopathic hemolytic anemia (MAHA), thrombocytopenia and schistocytes. They are often misdiagnosed as thrombotic thrombocytopenia purpura (TTP) and receive unnecessary therapy. Here, we report a case of a 60-year-old male who presented with thrombocytopenia and normocytic normochromic anemia. Anemia work-up was remarkable for severe B12 deficiency (<60 pg/mL) and a positive non-immune hemolysis panel. Peripheral smear was reviewed and showed anisocytes, poikilocytes, schistocytes and hypersegmented neutrophils. Vitamin B12 replacement (1000 mcg IM daily) was started, ADAMTS13 activity was sent and daily plasmapheresis was initiated. Over the next 3 days, the patient’s hemoglobin and platelets were stable and the hemolysis panel showed gradual improvement. On day 4, ADAMTS13 activity results came back normal at 61%. Accordingly, plasmapheresis was discontinued, parenteral B12 replacement was continued and that resulted in gradual improvement and eventually cessation of hemolysis and normalization of hemoglobin and platelets. In this patient, parietal cell autoantibodies were positive and so the diagnosis of pernicious anemia was made. Patients with severe vitamin B12 deficiency may present with features mimicking TTP such as MAHA, thrombocytopenia and schistocytosis. An early and accurate diagnosis of pseudo-TMA has a critical clinical impact with respect to administering the correct treatment with vitamin B12 replacement and avoiding, or shortening the duration of, unnecessary therapy with plasmapheresis.Keywords: vitamin B12 deficiency, pseudo-thrombotic microangiopathy, schistocytes  Fahmawi YCampos YKhushman MAlkharabsheh OManne AZubair HHaleema SPolski JBessette SDove Medical PressarticleVitamin B12 deficiencyPseudo-thrombotic microangiopathySchistocytesTherapeutics. PharmacologyRM1-950ENClinical Pharmacology: Advances and Applications, Vol Volume 11, Pp 127-131 (2019)
institution	DOAJ
collection	DOAJ
language	EN
topic	Vitamin B12 deficiency Pseudo-thrombotic microangiopathy Schistocytes Therapeutics. Pharmacology RM1-950
spellingShingle	Vitamin B12 deficiency Pseudo-thrombotic microangiopathy Schistocytes Therapeutics. Pharmacology RM1-950 Fahmawi Y Campos Y Khushman M Alkharabsheh O Manne A Zubair H Haleema S Polski J Bessette S Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
description	Yazan Fahmawi,1 Yesica Campos,1 Moh’d Khushman,2 Omar Alkharabsheh,2 Ashish Manne,2 Haseeb Zubair,2 Saadia Haleema,3 Jacek Polski,3 Sabrina Bessette11Department of Internal Medicine, University of South Alabama, Mobile, AL, USA; 2Department of Hematology-Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA; 3Department of Pathology, University of South Alabama, Mobile, AL, USACorrespondence: Yazan FahmawiDepartment of Internal Medicine, University of South Alabama, 2451 USA Medical Center Drive, Mobile, AL 36617, USATel +1 251 471 7891Fax +1 251 470 1652Email yfahmawi@health.southalabama.eduAbstract: Pseudo-thrombotic microangiopathy (pseudo-TMA) is a recognized, yet uncommon, clinical presentation of vitamin B12 deficiency. Patients with pseudo-TMA present with microangiopathic hemolytic anemia (MAHA), thrombocytopenia and schistocytes. They are often misdiagnosed as thrombotic thrombocytopenia purpura (TTP) and receive unnecessary therapy. Here, we report a case of a 60-year-old male who presented with thrombocytopenia and normocytic normochromic anemia. Anemia work-up was remarkable for severe B12 deficiency (<60 pg/mL) and a positive non-immune hemolysis panel. Peripheral smear was reviewed and showed anisocytes, poikilocytes, schistocytes and hypersegmented neutrophils. Vitamin B12 replacement (1000 mcg IM daily) was started, ADAMTS13 activity was sent and daily plasmapheresis was initiated. Over the next 3 days, the patient’s hemoglobin and platelets were stable and the hemolysis panel showed gradual improvement. On day 4, ADAMTS13 activity results came back normal at 61%. Accordingly, plasmapheresis was discontinued, parenteral B12 replacement was continued and that resulted in gradual improvement and eventually cessation of hemolysis and normalization of hemoglobin and platelets. In this patient, parietal cell autoantibodies were positive and so the diagnosis of pernicious anemia was made. Patients with severe vitamin B12 deficiency may present with features mimicking TTP such as MAHA, thrombocytopenia and schistocytosis. An early and accurate diagnosis of pseudo-TMA has a critical clinical impact with respect to administering the correct treatment with vitamin B12 replacement and avoiding, or shortening the duration of, unnecessary therapy with plasmapheresis.Keywords: vitamin B12 deficiency, pseudo-thrombotic microangiopathy, schistocytes
format	article
author	Fahmawi Y Campos Y Khushman M Alkharabsheh O Manne A Zubair H Haleema S Polski J Bessette S
author_facet	Fahmawi Y Campos Y Khushman M Alkharabsheh O Manne A Zubair H Haleema S Polski J Bessette S
author_sort	Fahmawi Y
title	Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
title_short	Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
title_full	Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
title_fullStr	Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
title_full_unstemmed	Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
title_sort	vitamin b12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review
publisher	Dove Medical Press
publishDate	2019
url	https://doaj.org/article/621a085badb4438a9c69b2ee4a49f6e6
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Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review

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