Intramuscular Vitamin B12 Injections Research Articles

Effect of dietary supplements of biotin, intramuscular injections of vitamin B12, or both on postpartum lactation performance in multiparous dairy cows

The current study was conducted to investigate the effects of dietary supplementation of biotin, intramuscular injections of vitamin B12 (VB12), or both beginning at the prepartum period on feed intake and lactation performance in postpartum dairy cows. Forty-eight dairy cows were allocated into 12 blocks, based on parity and milk yield of the previous lactation cycle, and randomly assigned to 1 of 4 treatments. Supplementation of VB12 (weekly intramuscular injections of 0 or 10 mg) and biotin (dietary supplements of 0 or 30 mg/d) were used in a 2 × 2 factorial arrangement in a randomized complete block design of 12 blocks with repeated measures. The study started at 3 wk before the expected calving date and ended at 8 wk after calving. Feed intake and lactation performance (milk yield and composition) were recorded weekly after calving. Blood variables were measured on d -10, 0, 8, 15, 29, 43, and 57 relative to calving. When VB12 was given, the cows had greater feed intake, better lactation performance and lower body weight loss in the postpartum period compared with animals without injection of VB12. The VB12-injected cows had lower plasma nonesterified fatty acids and β-hydroxybutyrate concentrations but higher plasma superoxide dismutase activity compared with cows without VB12. Cows fed a biotin supplement had higher milk protein yield (6 and 8 wk) and lactose yield (6-8 wk), compared with animals without biotin. However, under the present experimental conditions, we found no additive effect of a combined supplement of biotin and vitamin B12 on lactation performance of dairy cows.

Comparison of the efficacy of parenteral and oral treatment for nutritional vitamin B12 deficiency in children

ABSTRACT Objective: Although, oral replacement for vitamin B12 deficiency has been proved to be effective in adults, it is mainly treated with parenteral therapy. There are only few studies on oral replacement therapy of vitamin B12 with children. Therefore, we aimed to compare the efficacy of oral treatment with intramuscular vitamin B12 injections in pediatric population. Methods: Children with serum cobalamin concentrations less than 300 pg/mL, were treated either with the parenteral therapy or with oral vitamin B12. The primary and secondary outcomes of the study were the normalization of serum vitamin B12 and hemoglobin at first month, respectively. Results: Post-treatment vitamin B12 values were significantly higher than pre-treatment values (p-value <.001). Vitamin B12 increased from 183.5 ± 47 pg/mL to 482 ± 318.9 pg/mL in the oral and from 175.5 ± 42.5 pg/mL to 838 ± 547 pg/mL in the parenteral treatment arm (p-value <.001). Before treatment, 82 children had anemia according to age and gender. After treatment, 14/41 and 8/41 patients still had anemia at the first month of treatment in the parenteral and oral arms, respectively. The number of patients who still have anemia at the end of the 1st month of treatment did not significantly changed in the parenteral and oral treatment groups (p-value = .44). Conclusions: In this study, both oral and parenteral formulations were shown to be effective in normalizing vitamin B12 levels. We suggest that oral formulations may be considered to be safe as a first line treatment for vitamin B12 deficiency in children.

Deep vein thrombosis, an unreported first manifestation of polyglandular autoimmune syndrome type III.

SummaryA 71-year-old woman with severe right lower leg pain, edema and erythema was presented to the Emergency Department and was found to have an extensive deep vein thrombosis (DVT) confirmed by ultrasound. She underwent an extensive evaluation due to her prior history of malignancy and new hypercoagulable state, but no evidence of recurrent disease was detected. Further investigation revealed pernicious anemia (PA), confirmed by the presence of a macrocytic anemia (MCV=115.8fL/red cell, Hgb=9.0g/dL), decreased serum B12 levels (56pg/mL), with resultant increased methylmalonic acid (5303nmol/L) and hyperhomocysteinemia (131μmol/L), the presumed etiology of the DVT. The patient also suffered from autoimmune thyroid disease (AITD), and both antithyroglobulin and anti-intrinsic factor antibodies were detected. She responded briskly to anticoagulation with heparin and coumadin and treatment of PA with intramuscular vitamin B12 injections. Our case suggests that a DVT secondary to hyperhomocystenemia may represent the first sign of polyglandular autoimmune syndrome III-B (PAS III-B), defined as the coexistent autoimmune conditions AITD and PA. It is important to recognize this clinical entity, as patients may not only require acute treatment with vitamin B12 supplementation and prolonged anticoagulation, as in this patient, but may also harbor other autoimmune diseases.Learning pointsA DVT can be the first physical manifestation of a polyglandular autoimmune syndrome.Hyperhomocysteinemia secondary to pernicious anemia should be considered as an etiology of an unprovoked DVT in a euthyroid patient with autoimmune thyroid disease.Patients with DVT secondary to hyperhomocysteinemia should undergo screening for the presence of co-existent autoimmune diseases in addition to treatment with B12 supplementation and anticoagulation to prevent recurrent thromboembolism.

Effective vitamin B12 treatment can reduce serum antigastric parietal cell antibody titer in patients with oral mucosal disease.

Patients with serum antigastric parietal cell antibody (GPCA) positivity may have vitamin B12 deficiency and some oral symptoms. This study assessed the changes of serum GPCA titer in GPCA-positive patients after effective vitamin B12 treatment. Two hundred and ten GPCA-positive oral mucosal disease patients became oral symptom free (complete response) after 1.0-67.1months of treatment with regular and continuous intramuscular injection of vitamin B12 once per week. The changes of serum GPCA titers after treatment were evaluated in these 210 patients. We found a significant drop of the GPCA positive rate from 100% to 42.9% in our 210 complete response patients after effective vitamin B12 treatment (p<0.001). When 210 patients were further divided into seven subgroups according to the low to high serum GPCA titers, we noted that the higher serum GPCA titers decreased to significantly lower levels after treatment in all seven subgroups (all p<0.001). However, serum GPCA titers increased to significantly higher levels in 46 GPCA-positive control patients receiving only oral administration of two vitamin BC capsules (containing 10μg of vitamin B12) plus deficient hematinic supplements per day after a follow-up period of 2.7-27months. A maintenance vitamin B12 treatment once a month could retain the GPCA-negative status in 87% of treated-to GPCA-negative patients compared with those (10%) without further maintenance vitamin B12 treatment. Regular and continuous effective vitamin B12 treatment can reduce the relatively higher serum GPCA titers to significantly lower or undetectable levels in GPCA-positive patients.

Effects of intramuscular administration of folic acid and vitamin B12 on granulosa cells gene expression in postpartum dairy cows

The fertility of dairy cows is challenged during early lactation, and better nutritional strategies need to be developed to address this issue. Combined supplementation of folic acid and vitamin B12 improve energy metabolism in the dairy cow during early lactation. Therefore, the present study was undertaken to explore the effects of this supplement on gene expression in granulosa cells from the dominant follicle during the postpartum period. Multiparous Holstein cows received weekly intramuscular injection of 320 mg of folic acid and 10 mg of vitamin B12 (treated group) beginning 24 (standard deviation=4) d before calving until 56 d after calving, whereas the control group received saline. The urea plasma concentration was significantly decreased during the precalving period, and the concentration of both folate and vitamin B12 were increased in treated animals. Milk production and dry matter intake were not significantly different between the 2 groups. Plasma concentrations of folates and vitamin B12 were increased in treated animals. Daily dry matter intake was not significantly different between the 2 groups before [13.5 kg; standard error (SE)=0.5] and after (23.6 kg; SE=0.9) calving. Average energy-corrected milk tended to be greater in vitamin-treated cows, 39.7 (SE=1.4) and 38.1 (SE=1.3) kg/d for treated and control cows, respectively. After calving, average plasma concentration of β-hydroxybutyrate tended to be lower in cows injected with the vitamin supplement, 0.47 (SE=0.04) versus 0.55 (SE=0.03) for treated and control cows, respectively. The ovarian follicle ≥12 mm in diameter was collected by ovum pick-up after estrus synchronization. Recovered follicular fluid volumes were greater in the vitamin-treated group. A microarray platform was used to investigate the effect of treatment on gene expression of granulosa cells. Lower expression of genes involved in the cell cycle and higher expression of genes associated with granulosa cell differentiation before ovulation were observed. Selected candidate genes were analyzed by reverse transcription quantitative PCR. Although the effects of intramuscular injections of folic acid and vitamin B12 on lactational performance and metabolic status of animals were limited, ingenuity pathway analysis of gene expression in granulosa cells suggests a stimulation of cell differentiation in vitamin-treated cows, which may be the result of an increase in LH secretion.

PO-0299 Exclusive Breast Feeding Induced Dissociative Shock In A Child

Introduction As first choice of nutrition, breastfeeding is widely promoted but only sufficient for the first few months oflife. Breast feeding mothers following special diets may induce certain deficiencies in their children. Case report A 16 months old girl presents tothe Paediatric Emergency Department with extreme pallor, long-term vomiting and coughing, general weakness and drowsiness since several months. Physical examination reveals besides cachexia (weight << P3), an almost transparent pale skin, thin fine hair and a holosystolic heart murmur III/VI, also marked reduction of joy of life and obvious psychomotor development retardation. Thorough anamnesis reveals the toddler is exclusively breastfed since birth by a macrobiotic mother. Laboratory findings include extremely low hematocrit (Ht 12%)corresponding with dissociative shock; extreme erythroblastopenia in absence ofmegaloblastosis (MCV 90), low platelets (71,000/µL), very high LDH (10,000 IU/L) and triglycerides (400 mg%), elevated ferritin (440 ng/mL),but normal serum iron and TIBC. Methylmalonic aciduria following immeasurable serum vitamin B12 (< 1 pg/ml) is retained as a final diagnosis. Thegirl was successfully treated by daily intramuscular vitamin B12 injections duringseveral weeks. Conclusion In developed countries, children should not be exclusively breastfed during a prolonged period of time, especially when the motheris on a macrobiotic diet. Vitamin B12 deficiency as consequence of thisattitude, may lead to extreme erythroblastopenia and developmental retardation. This case is exceptional becauseof the unusual history as well as the very late and discrete appearance of symptoms.

Clinical observation on thoracic paravertebral nerve block with ozone treatment in patients with postherpetic neuralgia

Objective To analyze the clinical efficacy of thoracic paravertebral nerve block with ozone in the treatment of postherpetic neuralgia. Methods Eighty-five patients suffered postherpetic neuralgia were divided into 4 groups: Group A (oral drugs + intramuscular injection of vitamin B12 + local nerve block of lesion area), Group B (oral drugs + intramuscular injection of compound trivitamin B + local nerve block of lesion area), Group C (oral drugs + intramuscular injection of compound trivitamin B + thoracic paravertebral nerve block + local nerve block of lesion area), Group D (oral drugs + intramuscular injection of compound trivitamin B + thoracic paravertebral nerve block with ozone + local nerve block of lesion area). Treatment outcomes were evaluated by Visual Analogue Scale (VAS), Quality of Sleep (QS), Self-Rating Depression Scale (SDS) and C-reactive protein (CRP) before treatment and 4 weeks after treatment. Results After treatment, VAS, QS and SDS scores of 4 groups were lower than that before treatment, and the differences were statistically significant (P 0.05, for all), while a significant change in CRP was observed in patients of group D between before and after treatment (P < 0.05). The improvement of VAS, QS and SDS scores of group D was significantly better than other 3 groups (P < 0.05, for all). Conclusion Thoracic paravertebral nerve block combined with ozone is a quick and effective method for postherpetic neuralgia patients.

Treatment of confirmed B12 deficiency in hemodialysis patients improves Epogen&amp;reg; requirements

BackgroundVitamin B12 deficiency may have deleterious effects on end stage renal disease (ESRD) patients on maintenance hemodialysis, and may increase erythropoietin stimulating agent (ESA) resistance, yet little is known about its prevalence in this population.MethodsSerum vitamin B12 and methylmalonic acid (MMA) levels were drawn from ESRD patients prior to hemodialysis. All patients with MMA levels greater than 800 nmol/L had peripheral smears evaluated for B12 deficiency. Those with confirmatory smears were considered to be deficient and received intramuscular vitamin B12 injections for 4 months. Post-treatment MMA levels and smears were obtained. Erythropoietin dosages were monitored throughout the treatment period.ResultsThere was a 58% (60/103) prevalence of vitamin B12 deficiency as defined by a positive MMA level and a positive blood smear. Out of 52 patients with positive smears, 36 (69.2%) were negative on repeat analysis after B12 treatment. Mean Epogen® (EPO) dosages significantly decreased by 16,572 ± 41,902 units per month from baseline to the post-B12 t reatment period (P = 0.0082, Wilcoxon signed-rank test). Three months prior to treatment, the mean monthly EPO dose was 82,067 ± 47,906 and post, the mean EPO usage was 65,495 ± 39,691. Post treatment hemoglobin levels were not significantly different from baseline.ConclusionVitamin B12 supplementation was associated with a decrease in the mean dose of ESA administration while maintaining a stable hemoglobin level. Maintaining serum vitamin B12 levels improves functionality, and may allow a decrease in the use of ESA’s, avoiding their toxicities and significant costs.

Hypercobalaminemia Induced by an Energy Drink after Total Gastrectomy: A Case Report

We encountered a case of hypercobalaminemia induced by oral intake of an energy drink after total gastrectomy. The patient was referred to our hospital due to findings suspicious for gastric cancer on screening. A 20 mm type 0-IIc lesion was detected in the gastric subcardia on esophagogastroduodenoscopy. Total gastrectomy followed by Roux-en-Y reconstruction was performed. He was discharged without complications. His basal serum vitamin B12 level was initially maintained with monthly intramuscular injections of vitamin B12. After 9 months, his serum vitamin B12 level suddenly increased up to 36-fold higher than the normal range and persisted there for one year without vitamin B12 injections. The patient ultimately reported consuming half a bottle of an energy drink each day during this time period. This case demonstrates the risk of unexpected hypervitaminemia resulting from self-administration of nutritional supplements.

Effect of intramuscular injection of butaphosphan and vitamin B12 on the quality of fresh and cooled stallion semen

hyperactivation patterns of equine cryopreserved sperm. Three ejaculates were collected from each of three stallions (n1⁄49). Semen was packaged in 0.5-mL straws to a final concentration of 200 x 106 sperm/mL in Botu-Crio extender (Botupharma Animal Biotechnology) and frozen Frozen-thawed semen was then centrifuged in bovine in vitro fertilization medium supplemented with sodium bicarbonate and bovine serum albumin for the capacitation of equine sperm. The pellet was incubated in the same medium added with different concentrations of L-arginine (0; 2; 5; 10; 20 mM) for 0, 60, 120 and 300 minutes at 38 C under 5 % CO2. CASA was used for motility assessment. Spermwas considered hyperactivated when VCL was 180 mm/s and ALH was 12 mm. Data was analyzed using ANOVA and means in each time were compared with Tukey test, using SAS software. Total motility was not altered during neither incubation time nor treatment. There was a reduction in total motility when 10mM of L-arginine was added compared to 0, 2 and 5 mM (10 mM, time 0: 33.5 4.4; time 60: 29.3 5.4; time 120: 26.5 4.8; time 300: 14.9 3.0). A reduction in progressive motility was noted using concentration of 5 mM of L-arginine and higher (5 mM, time 0: 10.1 1.6; time 60: 10.9 2.3; time 120: 9.6 2.1; time 300: 5.9 1.2), however the concentration of 20 mM caused the greater decrease on this parameter (time 0: 5.7 0.8; time 60: 7.0 1.9; time 120: 7.5 1.9; time 300: 4.8 1.1). Increasing doses of L-arginine lead to a decrease in VAP, VSL and LIN (P < 0.05). VCL was not affected by the interaction of treatment and incubation time. ALH was not altered in the different incubation times or different treatments. STR, RAP and BCF results were lower for the cells treated with 20 mM of L-arginine compared to concentrations of 0, 5 e 10 mM in times 0, 60, 120 and 300 minutes of incubation. There was an interaction between treatments and incubation time (P < 0.05) in the percentage of hyperactivated cells. However, only at time 0 therewas difference among treatments, and hyperactivated cells percentage decreased in concentrations of L-arginineof 10mM. It canbe concluded that total motility and hyperactivated cells were reduced at 10mM L-arginine concentration and that increasing doses of L-arginine are prejudicial to motility sperm patterns in cryopreserved equine sperm.

Severe vitamin B12 deficiency in an exclusively breastfed 5-month-old Italian infant born to a mother receiving multivitamin supplementation during pregnancy

BackgroundIn infants, vitamin B12 deficiency may be due to an inborn error of absorption and metabolism, or nutritional problems.Case presentationAn exclusively breastfed 5-month-old Italian male infant, who was born after a normal full-term pregnancy to a vegan mother who was apparently daily treated with a multivitamin oral preparation during the second and third trimester, was hospitalised because of poor weight gain, feeding difficulties, severe pallor, muscle hypotonia and somnolence. Upon admission, his weight, length and head circumference were below the third percentile, he had an enlarged liver and spleen, and showed a significant delay in developmental milestones and communicative reactions. He had a hemoglobin level of 4.7 g/dL with an MCV of 84.2 fL, a white blood cell count of 4,680/mm3, and a platelet count of 45,000/mm3. His serum vitamin B12 level was 57 pg/mL (normal value 180–500 pg/mL) and serum folate level 12.8 ng/mL (normal value >3 ng/mL). The results of metabolic examinations excluded a cobalamin C disorder, whereas nutritional screening showed a serum iron concentration of 9 μg/dL and serum ferritin of 4 ng/mL. Magnetic resonance imaging of the brain showed mild dilatation of the lateral ventricles with diffuse delayed myelination. The child was diagnosed as having vitamin B12 and iron deficiency due to nutritional inadequacy and was immediately treated with packed red blood cells, intramuscular vitamin B12 injections, and iron supplementation. A few days after the start of therapy, his hemoglobin levels and other hematological parameters rapidly improved, and a clinical improvement was observed within few weeks. There was an increase in his achievement of developmental milestones, but his development was still retarded seven months after the start of therapy.ConclusionThis case underlines the importance of adequately controlling maternal vitamin B12 intake during pregnancy by means of supplementation which, in the case of vegan mothers, should be significantly greater than that usually given. Moreover, the supplementation should be continued during lactation in order to avoid the development of signs of deficiency that may be associated with persistent neurological problems in infants. The case also highlights the need to consider vitamin B12 deficiency in infants with severe anemia even if their hematological parameters do not indicate megaloblastic anemia because the concomitant presence of substantial iron deficiency may modify the characteristics of the anemia.

Pralatrexate: A novel synthetic antifolate for relapsed or refractory peripheral T-cell lymphoma and other potential uses

The pharmacology, pharmacokinetics, clinical trials, adverse effects, dosage, and economic considerations of pralatrexate (PDX) are reviewed. Peripheral T-cell lymphoma (PTCL) comprises approximately 15-20% of all aggressive lymphomas and 5-10% of all non-Hodgkin's lymphomas. Advanced PTCL is often refractory to traditional first-line chemotherapy regimens. PDX was developed as a synthetic folate analog antimetabolite that competitively inhibits dihydrofolate reductase (DHFR). This results in the depletion of thymidine, leading to interference with deoxyribonucleic acid synthesis and cancer cell death. PDX has a higher potency than methotrexate and edatrexate (EDX). The efficacy and safety of PDX have been demonstrated in the PROPEL trial, a prospective phase II trial in patients with relapsed or refractory PTCL. Patients with prior stem cell transplantation receiving PDX also had similar response rates (RRs). PDX was investigated on the treatment of relapsed or refractory cutaneous T-cell lymphoma, previously treated advanced non-small cell lung cancer and other solid malignancies. PDX has similar side effects to other DHFR inhibitors. The most common side effect of PDX is mucositis. The recommended dose of PDX is 30 mg/m(2) weekly once for 6 weeks in 7-week cycle until disease progresses or unacceptable toxicity for PTCL and may require dose reduction or discontinuation. Patients should be supplemented with oral folic acid and intramuscular vitamin B(12) injections. PDX provides clinical benefit to patients with relapsed or refractory PTCL with durable complete and partial responses in patients who had not responded to multiple prior treatment regimens.

Oral Vitamin B12 Replacement: An Effective Treatment for Vitamin B12 Deficiency After Total Gastrectomy in Gastric Cancer Patients

Vitamin B12 deficiency is a common long-term sequelae after total gastrectomy. Intramuscular injection of vitamin B12 is the only known treatment. We investigated the efficacy and safety of oral vitamin B12 replacement for gastric cancer patients with vitamin B12 deficiency after total gastrectomy. We performed a single-arm, open-label, fixed-drug dosage, prospective study (NCT00699478) involving gastric cancer patients who underwent total gastrectomy. Vitamin B12-deficient (<200 pg/ml) patients (n = 30) received daily oral vitamin B12 (dosage: 1500 μg mecobalamin) administration for 3 months. The primary outcome measurement was serum vitamin B12. The secondary outcome measurements were improvement of neurologic symptoms and hematologic findings (serum folate, homocysteine, ferritin, iron, total iron binding capacity, transferrin, and mean corpuscular volume). For comparison, another group of vitamin B12 deficient patients (n = 30) received intramuscular vitamin B12 injections (dosage: 1000 μg cyanocobalamin) weekly for 5 weeks and monthly thereafter for a total of 3 months in a separate study period. In both groups, mean serum vitamin B12 increased after 30 days of treatment and was maintained up to 90 days. No adverse effects related to oral or intramuscular vitamin B12 replacements were noted. Both groups showed decreased homocysteine levels. Before treatment, 29 patients in the oral vitamin B12 group had neurologic symptoms related to vitamin B12 deficiency. After oral vitamin B12 treatment, 28 patients experienced symptom relief, and 16 patients were symptom free. Oral vitamin B12 replacement is an effective and safe treatment for vitamin B12 deficiency in gastric cancer patients after total gastrectomy.

Effects of supplementary folic acid and vitamin B12 on hepatic metabolism of dairy cows according to methionine supply

The present experiment was undertaken to study the interactions between dietary supplements of rumen-protected methionine (RPM) and intramuscular injections of folic acid and vitamin B12, given from 3 wk before calving to 16 wk of lactation, on hepatic metabolism of lactating dairy cows. Sixty multiparous Holstein cows were assigned to 10 blocks of 6 cows each according to their previous milk production. Within each block, 3 cows were fed a diet calculated to supply Met as 1.83% of metabolizable protein, whereas the 3 other cows were fed the same diet supplemented with 18g of RPM calculated to provide Met as 2.23% of metabolizable protein. Within each level of Met, the cows received no vitamin supplement or weekly intramuscular injections of 160mg of folic acid alone or combined with 10mg of vitamin B12. Liver biopsies were taken at 2, 4, 8, and 16 wk of lactation. Liver concentrations of folates and vitamin B12 were increased by their respective supplements but this response to vitamin supplements was altered by methionine supply. Concentrations of total lipids and triglycerides increased in livers of cows fed RPM, whereas concentrations of cholesterol ester, cholesterol, diglycerides, phosphatidylethanolamine, and phosphatidylcholine were not affected. Folic acid, alone or combined with vitamin B12, tended to increase the ratio of phosphatidylcholine to phosphatidylethanolamine. Gene expression of 5,10-methylene-tetrahydrofolate reductase, microsomal transfer protein, and phosphatidylethanolamine methyltransferase were higher in liver of cows fed RPM supplements. The relative mRNA abundance of 5,10-methylene-tetrahydrofolate reductase and methylmalonyl-CoA mutase were increased by the combined injections of folic acid and vitamin B12, whereas those of methionine synthase and methionine synthase reductase were not affected by treatments. These results suggest that increasing supply of methyl groups, as preformed labile methyl groups or through methylneogenesis, affected the methylation cycle but had a limited effect on dairy cow performance. The observed effects of the combined supplement of folic acid and vitamin B12 on lactational performance of dairy cows probably result from an improvement of energy metabolism during early lactation.

多系統萎縮症との鑑別を要した多腺性自己免疫症候群関連パーキンソン症候群の1例

A 76-year-old woman experienced unsteadiness in walking in 1996. On the basis of clinical and imaging findings, the patient was diagnosed multiple system atrophy. During follow-up, her gait disturbance became aggravated leaving her unable to walk unaided. She was referred to our department in 2003. T2-weighted images on brain magnetic resonance imaging (MRI) revealed low signal intensity in both putamina and a linear high-signal-intensity area on their outsides. Single photon emission computed tomography (SPECT) disclosed a reduced blood flow in both corpora striata. These findings were consistent with the diagnosis of Parkinsonian-type multiple system atrophy. The patient had anti-glutamic acid decarboxylase (GAD) antibody-positive type 1 diabetes mellitus and a normal thyroid function, and was positive for antithyroid antibodies. She was not found to have anemia on blood tests, but was positive for intrinsic factor antibodies. Vitamin B12 was markedly reduced to below the detection limit. The findings suggested that the patient's condition was autoimmune polyglandular syndrome type 3. In 2004, treatment with intramuscular injection of vitamin B12 was initiated, after which the patient's gait disturbance was improved and she was able to walk unaided. In 2009, her unsteady gait returned and was again unable to walk unaided. Autoimmune encephalopathy was suspected, and thus high-dose intravenous immunoglobulin therapy was performed. Following treatment she was able to walk steadily. This case suggests the importance of detailed tests for autoantibodies, including endocrine autoantibodies, and the measurement of vitamin B12 and total homocysteine levels in view of the possibility of autoimmune polyglandular syndrome-related neurological disorders in diabetic patients with intractable neurological disorders that are difficult to diagnose.

Progressive unsteadiness in a 68-year-old man with longstanding abdominal pain and altered bowel habit

A 68-year-old man developed “pins and needles” of his fingertips and toes in December 2005 along with cramp-like muscle pains in his forearms and calves. Over the next 6 months...

Effects of supplements of folic acid, vitamin B12, and rumen-protected methionine on whole body metabolism of methionine and glucose in lactating dairy cows

The present experiment was undertaken to determine the effects of dietary supplements of rumen-protected methionine and intramuscular injections of folic acid and vitamin B12, given 3 wk before to 16 wk after calving, on glucose and methionine metabolism of lactating dairy cows. Twenty-four multiparous Holstein cows were assigned to 6 blocks of 4 cows each according to their previous milk production. Within each block, 2 cows were fed a diet estimated to supply methionine as 1.83% metabolizable protein, equivalent to 76% of methionine requirement, whereas the 2 other cows were fed the same diet supplemented daily with 18g of rumen-protected methionine. Within each diet, the cows were administrated either no vitamin supplement or weekly intramuscular injections of 160mg of folic acid plus 10mg of vitamin B12. To investigate metabolic changes at 12 wk of lactation, glucose and methionine kinetics were measured by isotope dilution using infusions of 3[U-13C]glucose, [13C]NaHCO3 and 3[1-13C,2H3] methionine. Milk and plasma concentrations of folic acid and vitamin B12 increased with vitamin injections. Supplementary B-vitamins increased milk production from 34.7 to 38.9±1.0 kg/d and increased milk lactose, protein, and total solids yields. Whole-body glucose flux tended to increase with vitamin supplementation with a similar quantitative magnitude as the milk lactose yield increase. Vitamin supplementation increased methionine utilization for protein synthesis through increased protein turnover when methionine was deficient and through decreased methionine oxidation when rumen-protected methionine was fed. Vitamin supplementation decreased plasma concentrations of homocysteine independently of rumen-protected methionine feeding, although no effect of vitamin supplementation was measured on methionine remethylation, but this could be due to the limitation of the technique used. Therefore, the effects of these B-vitamins on lactation performance were not mainly explained by methionine economy because of a more efficient methylneogenesis but were rather related to increased glucose availability and changes in methionine metabolism.

Effects of Intramuscular Injections of Vitamin B12 on Lactation Performance of Dairy Cows Fed Dietary Supplements of Folic Acid and Rumen-Protected Methionine

The experiment was undertaken to determine the effects of i.m. injections of vitamin B12 on lactational performance of primiparous dairy cows fed dietary supplements of folic acid and rumen-protected methionine from 4 to 18 wk of lactation. Fourteen primiparous Holstein cows were assigned to 7 blocks of 2 cows each, according to milk production during the third week of lactation. All cows were fed a basal diet supplemented daily with rumen-protected methionine (18g of supplement, to bring the estimated supply of methionine to 2.2% of metabolizable protein) plus folic acid (4mg per kg of BW). Within each block, the cows received a weekly i.m. injection (2mL) of saline or 10mg of vitamin B12. Milk production was recorded daily. Milk and blood were sampled every 2 wk. Supplementary vitamin B12 increased energy-corrected milk from 25.8 to 29.0 (SE 1.6) kg/d, as well as milk yields of solids [3.52 to 3.90 (SE 0.22) kg/d], fat [0.87 to 1.01 (SE 0.06) kg/d], and lactose [1.48 to 1.64 (SE 0.11) kg/d]. Supplementation also increased concentrations and amounts of vitamin B12 secreted in milk but had no significant effect on dry matter intake and concentrations and amounts of folates in milk. Packed cell volume, blood hemoglobin, and serum vitamin B12 were increased by supplementary vitamin B12, whereas serum methylmalonic acid was decreased. Serum concentrations of sulfur amino acids were unchanged by treatment. These findings support the hypothesis that, in early lactation, supply of vitamin B12 was not optimal and limited the lactation performance of the cows.

Slowly Progressive Type 1 Diabetes Mellitus Associated with Vitiligo Vulgaris, Chronic Thyroiditis, and Pernicious Anemia

A 81-year-old woman was diagnosed as having diabetes mellitus (DM) at 58 years of age. She started insulin therapy the following year, but her blood sugar levels were poorly controlled. At the age of 75, she tested positive for the anti-GAD antibody (7.8 U/ml) and was diagnosed as having slowly progressive type 1 DM (SPIDDM), as well as vitiligo vulgaris. At 78 years of age, chronic thyroiditis was diagnosed after positive tests for anti-thyroid peroxidase antibody and anti-thyroglobulin antibody. At the age of 81, general fatigue and jaundice appeared concomitantly with severe anemia, with Hb levels at 5.2 g/dl. Low serum vitamin B12 levels and the finding of erythroblastic hyperplasia with megaloblasts in bone marrow led to the diagnosis of pernicious anemia. Anemia was alleviated by intramuscular injections of vitamin B12. The patient developed chronic thyroiditis, vitiligo vulgaris, and pernicious anemia concomitantly with SPIDDM, and was diagnosed as having polyglandular autoimmune syndrome type III. Attention should be paid to these potentially associated autoimmune diseases in daily practice during the follow-up of SPIDDM patients.

Normalization of plasma vitamin B12 concentration by intranasal hydroxocobalamin in vitamin B12-deficient patients

BACKGROUND & AIMS: Patients with previous stomach and terminal ileum resections are often treated with intramuscular vitamin B12 injections. Disadvantages are, on a worldwide scale, the frequent need for medical personnel to administer injections and the sometimes painful way of application. This study was designed to investigate the feasibility of intranasal hydroxocobalamin suppletion in cobalamin-deficient patients and to assess whether intranasal hydroxocobalamin application could be an alternative for intramuscular injection.METHODS: Six patients with plasma cobalamin concentrations of < 200 ng/L were recruited. A dose of 1500 micrograms hydroxocobalamin was applied intranasally at days 0, 14, and 21. Plasma cobalamin concentrations were determined 1 hour after hydroxocobalamin application and on days 0, 7, 21, 28, and 35.RESULTS: All patients showed substantial increase of cobalamin concentrations 1 hour after intranasal application. In these 6 patients, there was an eightfold increase of mean baseline cobalamin concentrations. All patients showed a sustained increase of baseline cobalamin concentrations 1 week after prior intranasal application of hydroxocobalamin. No side effects were noted.CONCLUSIONS: Intranasal application of hydroxocobalamin in cobalamin-deficient patients results in fast nasal absorption and leads to sustained increase of baseline cobalamin concentrations.(Gastroenterology 1997 Aug;113(2):430-3)