Hemolytic anemia with thrombocytopenia and organ damage raises suspicion for thrombotic microangiopathy (TMA), a pathology that results in thrombosis within the small vessels secondary to endothelial injury. While usually attributed to atypical hemolytic uremic syndrome (aHUS) or thrombotic thrombocytopenic purpura (TTP), an increasingly recognized and treatable entity is pseudo-thrombotic microangiopathic anemia (pseudo-TMA) secondary to severe vitamin B-12 deficiency.While TMA often requires expensive diagnostic testing and can lead to invasive treatment options such as plasma exchange, immunosuppression, and/or complement cascade blocking, pseudo-TMA requires only vitamin supplementation. Therefore, the prompt and accurate diagnosis of this entity is important for the clinician to recognize in order to avoid unnecessary health costs and institute appropriate treatment.We present the case of a 51-year-old male without any past medical history, who presented with generalized weakness, dyspnea on exertion, and decreased exercise tolerance for several months and was found to have severe microangiopathic anemia with work-up concerning for TTP. After stabilization, he was found to have severe B-12 deficiency secondary to newly diagnosed pernicious anemia and was treated with subcutaneous B-12 injections with improvement in clinical symptoms and laboratory parameters. This presentation highlights the need for prompt diagnosis and high clinical suspicion for vitamin deficiencies as a source of pseudo-microangiopathy.