Abstract
IntroductionVitamin B12 deficiency can result in macrocytic anemia. Neurologic abnormalities of B12 deficiency include sensory deficits, loss of deep tendon reflexes, movement disorders, neuropsychiatric changes and seizures. Segmental involvement of the distal ileum, such as in tuberculosis, can cause vitamin B12 deficiency. To our knowledge, macrocytic anemia with unusual manifestations such as brain atrophy and seizures due to intestinal tuberculosis has not been reported in the literature.Case presentationA 14-year-old girl presented with complaints of paraplegia, ataxia, fever and fatigue that had started a few months earlier and which had been getting worse in the last three weeks. Her laboratory results were indicative of macrocytic anemia with a serum B12 level <100 (normal, 160–970) pg/ml and hypersegmented neutrophils. Her MRI findings showed brain atrophy. Her fever workup eventually led to the diagnosis of tuberculosis which was documented by bone marrow aspiration smear & culture. A small bowel series showed that tuberculosis had typically involved the terminal ileum which had resulted in vitamin B12 deficiency. She was treated for vitamin B12 deficiency and tuberculosis. Her fever ceased and her hemoglobin level returned to normal. At present, she can eat, write, and speak normally as well as walk and ride a bicycle.ConclusionVitamin B12 deficiency should be considered in patients with neurologic features such as paresthesia, sensory deficits, urinary incontinence, dysarthria, and ataxia. The underlying cause of B12 deficiency should be determined and treated to obviate the patients' need for long term vitamin B12 therapy.
Highlights
Vitamin B12 deficiency can result in macrocytic anemia
Vitamin B12 deficiency should be considered in patients with neurologic features such as paresthesia, sensory deficits, urinary incontinence, dysarthria, and ataxia
Vitamin B12 deficiency leads to delayed DNA synthesis in rapidly growing hematopoietic cells, and can result in macrocytic anemia
Summary
Vitamin B12 deficiency causes neurologic abnormalities such as paresthesia, movement disorders, developmental regression and neuropsychiatric changes [1]. Our patient's seizures may have been due to B12 deficiency We believe she can taper and end the antiepileptic drugs under close EEG and continual symptom monitoring, after complete recovery [4]. After treatment with anti-tuberculosis drugs, her fever terminated, her hemoglobin level elevated and her general condition improved. This response to therapy was a good indication confirming the involvement of tuberculosis. Segmental involvement of the distal ileum, such as seen in tuberculosis, regional enteritis and Whipple's disease, can cause macrocytic anemia without any other manifestations of intestinal malabsorption such as steatorrhea [5,6]. Vitamin B12 deficiency should be considered in patients with neurologic features such as paresthesia, sensory deficits, urinary incontinence, dysarthria, and ataxia. MRI: Magnetic Resonance Imaging, LP: Lumbar puncture, EMG/NCV: Electromyography/Nerve Conduction Velocity, CBC: Complete Blood Count, MCV: Mean Corpuscular Volume
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