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    1. Pancytopenia and B Symptoms in a Previously Healthy Female Robert J. Hoffman MD December 20, 2006

    2. Presentation 34 year old female with a history of hypothyroidism presents with abdominal pain, weakness, night sweats, fevers and weight loss. 15 lb unintentional weight loss over 6 weeks Fevers to 101 Recent drenching night sweats Diffuse moderate abdominal pain

    3. HPI 5-6 weeks of progressive diffuse abdominal pain Waxes and wanes Better with food Moderate severity New DOE restricting her activity as well Recent diagnosis of Barrett esophagus

    4. PMH Hypothyroidism Barrett esophagus based on recent EGD GERD

    5. Medications Prilosec Synthroid OCP

    6. Social History No tobacco, alcohol or illegal drug use Single Works as an accountant

    7. Physical Examination Vitals: T: 98.5 P: 98 RR: 16 BP: 109/41 General: Comfortable appearing, pale, NAD Abd: soft, moderate epigastric and RUQ tenderness. No organomegaly No LAD Otherwise normal exam.

    8. Labs

    9. 10mm, 8mm, 4mm liver lesions 5 x 3 cm pelvic mass Small amount of pelvic ascites CT Abdomen

    10. Initial Hospital Course MRI orderd to f/u pelvic mass. Hematology consult obtained, bone marrow biopsy planned for Monday. PRBC transfusion Haptoglobin < 6, consistent with hemolysis LDH elevated

    11. Hospital Course MRI reveals pelvic mass to be an enlarged vaginal vault. u/s fails to confirm liver nodules Decreased bone marrow signal found on MRI c/w marrow replacement

    12. Summary Pancytopenia B symptoms Abdominal pain Decreased marrow signal Intravascular hemolysis

    13. Phew! B12 returns 78 pg/ml Homocysteine and methylmalonic acid elevated Anti-parietal cell antibody positive. B12 supplements initiated Bone marrow shows hypercellularity and erythroid hyperplasia, consistent with vitamin B12 deficiency

    14. Outcome At one week follow up patient states she feels better than she has in years Hemoglobin was 9.2 g/dl on d/c and 11.8 g/dl at one week follow up. Other cytopenias resolve.

    15. Pernicious Anemia Autoimmune disorder with T-cell mediated immune response to intrinsic factor and gastric parietal cells Atrophic gastritis Achlorhydria

    16. Autoimmune Disorders Hashimotos thyroiditis DM I Celiac sprue

    17. B12 Deficiency Megaloblastic anemia Leukopenia Thrombocytopenia Peripheral neuropathy Psychosis, personality changes, memory loss

    19. Other Findings Ineffective erythropoiesis ? mild hemolysis Achlorhydria Elevated gastrin Adenocarcinoma and carcinoid tumors Atrophic glossitis

    20. Diagnosis Low B12 OR Low Normal B12 with elevated MMA/homocysteine Elevated intrinsic factor ab, anti-parietal cell antibody, elevated gastrin Atrophic gastritis on EGD Schilling test

    21. Treatment Historically treatment is with IM B12 Recent data suggests po a reasonable alternative Second pathway for B12 absorption without intrinsic factor

    22. Treatment Small 1998 study randomized pts to cobalomin 1 mg IM at scheduled intervals vs. daily 2mg orally Higher B12 and lower MMA levels in oral group than IM group at 120 days f/u Only 33 patients Only 7 with clear pernicious anemia

    23. Treatment 60 patients with megaloblastic anemia randomized to 1g IM vs. 1g po daily for 10 days followed by once/wk followed by monthly Hgb, B12, retic, MCV increased in both groups similarly In patients with neurologic deficits, 78% improved in IM vs. 75% in po Small study, etiology of deficiency not fully tested

    24. Treatment PO therapy a reasonable alternative. Some experts recommend initial IM therapy, especially in the presence of neurologic symptoms. PO therapy standard of care in Canada and Sweden.

    25. Classic Case? Pancytopenia Hemolysis Peripheral smear Glossitis (maybe)

    26. Incongruities Barrett esophagus in a patient with achlorhydria? B symptoms

    27. Take Home Points Think of B12 deficiency in patients with cytopenias (not just anemia!), neurologic dysfunction. Confirm with B12 +/- MMA & homocysteine. Oral therapy is probably preferred.