A case of asymptomatic pancytopenia with clinical features of hemolysis as a presentation of pernicious anemia

Abstract

Pernicious anemia is an autoimmune disease with a variety of clinical presentations. We describe a case of pernicious anemia presenting with pancytopenia with hemolytic features. Further workup revealed very low vitamin B12 levels and elevated methylmalonic acid. It is important for a general internist to identify pernicious anemia as one of the cause of pancytopenia and hemolytic anemia to avoid extensive workup. Pernicious anemia can present strictly with hematological abnormalities without neurological problems or vice versa as in our case.

Fooled by the fragments: vitamin B12 deficiency masquerading as thrombotic thrombocytopenic purpura

“…The hemolytic anemia seen in vitamin B12 deficiency may be due to a combination of extramedullary and intramedullary hemolysis. The hypercoagulability and endothelial dysfunction associated with hyperhomocysteinemia may lead to erythrocyte fragmentation comparable to that observed in microangopathic hemolytic anemia/TTP [ 5 , 6 ]. In the cases described, however, bilirubin levels were normal to minimally elevated, suggesting an intramedullary process deviating from that of true TTP.…”

Hemolytic anemia in a 26-year-old woman with vomiting and fatigue

“…11 Varying blood smear features have been reported, including hypersegmented neutrophils and macrocytosis, schistocytosis, normocytic and normochromic anemia, anisocytosis and poikilocytosis. [3][4][5][6][7][8][9][10][11] In our literature review, patients who presented with hemolysis usually had vitamin B 12 levels of less than 100 pg/mL. A few case reports, however, have described hemolysis in patients with vitamin B 12 levels between 100 and 200 pg/mL (Box 2).…”

“…Existing case reports and case series have reported substantial heterogeneity in the clinical presentation of patients with hemolysis secondary to vitamin B 12 deficiency. [3][4][5][6][7][8][9][10][11] In our review of the literature, these patients most commonly presented with fatigue, asthenia, sensory neuropathy or jaundice. A small proportion of patients, however, presented asymptomatically, with evidence of hemolysis noticed incidentally on blood work (Box 2).…”

Pancitopenia como apresentação inicial de anemia perniciosa: relato de caso de uma abordagem minimamente invasiva

“…Nesse sentido, os profissionais da saúde devem estar aptos a identificar corretamente a etiologia do quadro de modo que esta hipovitaminose possa ser considerada como possível diagnóstico diferencial. Isso permite a redução das investigações invasivas e de alto custo, assim como exposições desnecessárias dos pacientes [1][2][3][4].…”