Transcript J. Matthew Rhinewalt, MD, PGY-4 Internal Medicine/Pediatrics University of MS Medical Center Jackson, MS 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

Vitamin B12 deficiency:
 Multi-organ dysfunction
 Variety of clinical presentations
 May present clinically similar to thrombotic
thrombocytopenic purpura (TTP)
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

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

Pertinent (+) labs:
 WBC 3.3
 LDH >2500
 Hgb 5
 haptoglobin <10
 Hct 15%
 total bilirubin 2.5
 MCV 108
(indirect 1.7)
 Creatinine 1.6
(baseline 0.8)(baseline
0.7)
 Plt 58,000
 Retic count 0.9%
(corrected)
Case Description - Labs

Pertinent (-/nrl) labs:
 Glucose
 Ammonia
 Urine drug screen
 Fecal occult blood
 Alcohol level
testing
 Prothrombin time
 Creatine kinase
 Troponin
Case Description - Labs

Blood Smear:
 Hypersegmented neutrophils
 Rare schistocytes
 Many tear drop cells
Moll. NEJM. 1996; 335:323. August 1, 1996.
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
#1 - Thrombotic Thrombocytopenic Purpura
#2 - Vitamin B12 Deficiency
#3 - Leukemia / Bone Marrow Malignancy
Management
 Hematology
consult
 Plasmapheresis for possible TTP
while awaiting labs
Therapy
4 units PRBC transfusion: hospital day 1
 Plasmapheresis: hospital day 1-3

(12 bags FFP each treatment)
Results

Clinical improvement after first
plasmapheresis:
 hemolysis
 mental status
 renal function
ADMIT
HOSP DAY 2
LDH
>2500
979
Haptoglobin
<10
15
Bilirubin
3.4
2.6
Creatinine
1.6
0.98
Interesting Results
AdamTS13 activity
 Folate RBC level
 Leukemia/lymphoma panel


Vitamin B12 level
(resulted on hospital day 3)
normal
normal
normal
30pg/mL
Continued Management

On hospital day 3:
Vitamin B12 1000mcg IM daily
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?
How much vitamin B12 is in FFP?
 Unable
to locate a reference
 Is it degraded during processing?
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

Vitamin B12 levels in FFP were
comparable to serum levels of nondeficient patients
 need for baseline B12 level
 signs & symptoms of vitamin B12
deficiency may likely improve if given
FFP
Thank You
Mohamed A. Asfour, MD
 Taylor Pruett, MD
 John C. Henegan, MD
