Why did vitamin B12 deficiency respond to plasmapheresis?
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Transcript 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