Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review

Abstract

Pseudo-thrombotic microangiopathy (pseudo-TMA) is a recognized, yet uncommon, clinical presentation of vitamin B12 deficiency. Patients with pseudo-TMA present with microangiopathic hemolytic anemia (MAHA), thrombocytopenia and schistocytes. They are often misdiagnosed as thrombotic thrombocytopenia purpura (TTP) and receive unnecessary therapy. Here, we report a case of a 60-year-old male who presented with thrombocytopenia and normocytic normochromic anemia. Anemia work-up was remarkable for severe B12 deficiency (<60 pg/mL) and a positive non-immune hemolysis panel. Peripheral smear was reviewed and showed anisocytes, poikilocytes, schistocytes and hypersegmented neutrophils. Vitamin B12 replacement (1000 mcg IM daily) was started, ADAMTS13 activity was sent and daily plasmapheresis was initiated. Over the next 3 days, the patient's hemoglobin and platelets were stable and the hemolysis panel showed gradual improvement. On day 4, ADAMTS13 activity results came back normal at 61%. Accordingly, plasmapheresis was discontinued, parenteral B12 replacement was continued and that resulted in gradual improvement and eventually cessation of hemolysis and normalization of hemoglobin and platelets. In this patient, parietal cell autoantibodies were positive and so the diagnosis of pernicious anemia was made. Patients with severe vitamin B12 deficiency may present with features mimicking TTP such as MAHA, thrombocytopenia and schistocytosis. An early and accurate diagnosis of pseudo-TMA has a critical clinical impact with respect to administering the correct treatment with vitamin B12 replacement and avoiding, or shortening the duration of, unnecessary therapy with plasmapheresis.

Keywords: pseudo-thrombotic microangiopathy; schistocytes; vitamin B12 deficiency.

Figure 1

Peripheral blood smear with a nucleated red blood cell, polychromasia, “fragmented” RBCs and thrombocytopenia. The arrow points to a dysmorphic “fragmented” RBC (Wright ‘s stain, original magnification x1000).

Figure 2

Timeline summary showing gradual improvement of ongoing hemolysis demonstrated by decreasing bilirubin and serum lactate dehydrogenase (LDH) levels.

Figure 3

Timeline summary showing gradual improvement of anemia and thrombocytopenia demonstrated by increasing hemoglobin (Hb) and platelets. Two packed red blood cells were transfused on day 0 and day 4.