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Why did vitamin B12 deficiency respond to plasmapheresis ? PowerPoint PPT Presentation


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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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Why did vitamin B12 deficiency respond to plasmapheresis ?

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Why did vitamin b12 deficiency respond to plasmapheresis

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


Why did he rapidly improve with plasmapheresis

Why did he rapidly improve with plasmapheresis?


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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