![]() This leads to fragmentation of erythrocytes to schistocytes as seen in our patient. The biological effects of endothelial dysfunction are vasoconstriction, increased platelet aggregation, activation of coagulation system and monocyte adhesion to the endothelium. High homocysteine in the serum causes endothelial dysfunction. Deficiency of Vitamin B 12 also results in an elevated serum homocysteine. Serum LDH levels are higher in vitamin B 12 deficiency than peripheral hemolysis from TTP.Īn increase in the RBC membrane rigidity and a decrease in erythrocyte deformability were reported in B 12 deficiency. This manifests clinically as hemolytic anemia with indirect hyperbilirubinemia and an elevated serum LDH levels. Deficiency of vitamin B 12 leads to an arrest in the maturation of nucleated precursors and results in hemolysis in the bone marrow. Vitamin B 12 is needed for the synthesis of Deoxy ribo Nucleic Acid (DNA) and division of blood cells. Laboratory data on the day of admission and 4 months prior to presentation are described in Table 1. Peripheral smear revealed numerous schistocytes, anisocytosis and macro-ovalocytes ( Figure 1). Prothrombin time, partial thromboplastin time, serum fibrinogen, and serum fibrin degradation product levels were within normal limits. Serum Lactate De Hydrogenase (LDH) was elevated at 4579 U/l. Total bilirubin was elevated at 2.2 mg/dl, and direct bilirubin was 0.5 mg/dl with normal liver enzymes. Electrolytes and serum creatinine were normal. Initial laboratory tests showed that hemoglobin was 5.7 g/dl, hematocrit 15.7%, platelet count was 81,000/mm 3 and white blood cell count 4,200/mm 3. Rest of the physical examination was normal. ![]() Neurological examination showed normal sensations and power in her lower extremities. Examination of the abdomen did not show hepatosplenomegaly. Patient was a febrile, and hemodynamically stable. Her sister had iron deficiency anemia and grandfather was treated for chronic myeloid leukemia. ![]() Patient drank alcohol occasionally, never smoked or used recreational drugs. Patient was taking lisinopril and ranitidine. Patient had chronic diarrhea and weight loss of 5 lbs. Patient denied fever, shortness of breath, or weakness of legs. Past medical history included hypertension and gastro-esophageal reflux disease. Pernicious anemia was confirmed by the presence of anti-intrinsic factor antibodies, elevated serum gastrin level and atrophic gastritis.Ī 31-year-old Caucasian woman presented with fatigue and paresthesia of both feet for 1 week. Treatment with intra-muscular vitamin B 12 led to symptomatic and hematologic improvement. On re-evaluation, vitamin B 12 was found to be low. However, platelet count worsened despite plasmapheresis for 4 days. Plasmapheresis was initiated for possible TTP. Thrombotic thrombocytopenic purpura (TTP) was suspected due to the constellation of sub-acute onset of fatigue and paresthesia along with thrombocytopenia, schistocytes and an elevated LDH. Peripheral smear revealed numerous schistocytes, anisocytosis and macro-ovalocytes. Prothrombin time, partial thromboplastin time, serum fibrinogen, and serum fibrin degradation product levels were normal. Indirect bilirubin and serum Lactate De Hydrogenase were elevated. Initial laboratory tests showed severe anemia, and low platelets. Examination revealed scleral icterus and pallor. A 31-year-old Caucasian woman presented with fatigue and paresthesia of both feet for 1 week.
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