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Why did vitamin B12 deficiency respond to plasmapheresis ?

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J. Matthew Rhinewalt , MD, PGY-4 Internal Medicine/Pediatrics University of MS Medical Center Jackson, MS. Why did vitamin B12 deficiency respond to plasmapheresis ?. Introduction. Vitamin B12 deficiency: Multi-organ dysfunction Variety of clinical presentations

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slide1
J. Matthew Rhinewalt, MD, PGY-4

Internal Medicine/Pediatrics

University of MS Medical Center

Jackson, MS

Why did vitamin B12 deficiency respond to plasmapheresis?

introduction
Introduction
  • Vitamin B12 deficiency:
    • Multi-organ dysfunction
    • Variety of clinical presentations
    • May present clinically similar to thrombotic thrombocytopenic purpura (TTP)
case description history
Case Description – History
  • 62 y/o man
    • CC: confusion
    • HPI:
      • 3 days of confusion per emergency medical personnel
      • pt unable to answer any questions upon presentation and no family present
    • PMH: type 2 diabetes, seizure disorder, alcoholism, illicit drug use
case description physical exam
Case Description – Physical Exam
  • Pertinent Physical Exam
    • Temperature 100.5°F
    • Weight 185lbs
    • Sleepy/confused
    • Jugular venous pressure 10cm
    • Liver edge 3cm below right costal margin
    • No evidence of bleeding or petechiae
    • Negative bedside fecal occult blood testing
case description labs
Case Description - Labs
  • Pertinent (+) labs:
    • WBC 3.3
    • Hgb 5
    • Hct 15%
    • MCV 108
    • Plt 58,000
    • Retic count 0.9% (corrected)
    • LDH >2500
    • haptoglobin <10
    • total bilirubin 2.5 (indirect 1.7)
    • Creatinine 1.6

(baseline 0.8)(baseline 0.7)

case description labs1
Case Description - Labs
  • Pertinent (-/nrl) labs:
    • Glucose
    • Urine drug screen
    • Alcohol level
    • Creatine kinase
    • Troponin
    • Ammonia
    • Fecal occult blood testing
    • Prothrombin time
case description labs2
Case Description - Labs
  • Blood Smear:
    • Hypersegmented neutrophils
    • Rare schistocytes
    • Many tear drop cells

Moll. NEJM. 1996; 335:323. August 1, 1996.

problems
Problems
  • Fever
  • Hemolytic/Macrocytic Anemia
  • Low Reticulocyte Count
  • Thrombocytopenia
  • Altered Mental Status
  • Acute Kidney Injury
  • History of Alcoholism, Type 2 Diabetes, Seizure Disorder
initial differential diagnosis
Initial Differential Diagnosis

#1 - Thrombotic Thrombocytopenic Purpura

#2 - Vitamin B12 Deficiency

#3 - Leukemia / Bone Marrow Malignancy

management
Management
  • Hematology consult
    • Plasmapheresis for possible TTP while awaiting labs
therapy
Therapy
  • 4 units PRBC transfusion: hospital day 1
  • Plasmapheresis: hospital day 1-3

(12 bags FFP each treatment)

results
Results
  • Clinical improvement after first plasmapheresis:
    • hemolysis
    • mental status
    • renal function
interesting results
Interesting Results
  • AdamTS13 activity normal
  • Folate RBC level normal
  • Leukemia/lymphoma panel normal
  • Vitamin B12 level 30pg/mL

(resulted on hospital day 3)

continued management
Continued Management
  • On hospital day 3:

Vitamin B12 1000mcg IM daily

upon discharge hospital d ay 8
Upon Discharge (Hospital Day 8)
  • PE: mental status back to baseline
  • Labs:
    • Creatinine back to baseline
    • Hgb 10
    • Platelet count 124,000
    • Reticulocyte count 13% (corrected)
    • LDH 777
how much vitamin b12 is in ffp
How much vitamin B12 is in FFP?
  • Unable to locate a reference
  • Is it degraded during processing?
how much vitamin b12 is in ffp1
How much vitamin B12 is in FFP?
  • Thank you to Dr. Asfour
    • UMMC blood bank pathologist
    • Random sampling of 4 bags of FFP for B12 levels
      • Results: 300 – 500 pg/mL
  • Our patient’s level was 30 pg/mL
clinical impact
Clinical Impact
  • Vitamin B12 levels in FFP were comparable to serum levels of non-deficient patients
    • need for baseline B12 level
    • signs & symptoms of vitamin B12 deficiency may likely improve if given FFP
thank you
Thank You
  • Mohamed A. Asfour, MD
  • Taylor Pruett, MD
  • John C. Henegan, MD
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