Vitamin B12 deficiency is classically associated with megaloblastic anemia. Possible cobalamin deficiency is not investigated once hemolysis is seen. Around 2.5% of cases can present as pseudo-thrombotic microangiopathy (TMA). A swift identification of this means the difference between an easy solution and a protracted one for the patient. A 74-year-old man with no past medical history presented with exertional dyspnea, fatigue, and increasing anorexia over two weeks. Physical examination including a neurological examination was normal. Laboratory tests revealed pancytopenia, unconjugated hyperbilirubinemia, elevated LDH (lactate dehydrogenase), low haptoglobin, and fragmented red blood cells (RBCs) on the peripheral smear, but normal FDP (fibrinogen degradation product) and fibrinogen. The absolute reticulocyte count was reduced as opposed to the expected elevation. Vitamin B12 levels were undetectable, and severe cobalamin deficiency from pernicious anemia was found to be the paramount etiology. Cobalamin deficiency causing pseudo-TMA baffles most physicians. Advanced pernicious anemia is thought to cause intramedullary hemolysis, resulting in peripheral pancytopenia. The fragile RBCs are easily sheared, producing schistocytosis without platelet microthrombi. In contrast to hemolytic anemias, reticulocyte count is low given the unavailability of B12 for erythropoiesis. Reticulocytopenia is a universal finding in cases of pseudo-TMA. Around 38.8% of cases with pseudo-TMA are misdiagnosed as thrombotic thrombocytopenic purpura and treated with plasma product therapy. Keeping an eye out for reticulocytopenia in cases of hemolysis could mean a world of difference for the patient.

Anemia is the most common hematological disorder. It is commonly a manifestation of an underlying disease. Its causes are multifactorial, including but not limited to nutritional deficiencies, chronic conditions, inflammatory processes, medications, malignancy, renal dysfunction, hereditary diseases, and bone marrow disorders. We present a case of a patient exhibiting anemia related to cold agglutin disease and severe B12 deficiency secondary to pernicious anemia.