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Vitamin B12 deficiency lakes years to develop, and its symptoms arc subtle. Typically, patients develop glossitis with a smooth, red tongue; mild jaundice (lemon-yellow skin color): and neurologic changes. The latter includes paresthesias, abnormal position and vibration sensation, and gait ataxia from degeneration of the posterolateral columns of the spinal cord. Various psychiatric syndromes (including dementia, depression, and mania) may occur. The neuropsychiatry disorders may occur without anemia and often do not improve when the deficiency is treated. However, the hematologic problems are reversible.
Vitamin B12 deficiency has four stages: negative vitamin Bi? balance, vitamin B12 depletion, vitamin B12 deficient erythropoiesis, and vitamin B12 deficiency anemia. The first two stages are characterized by a serum vitamin B12 level of < 300 pg/mL and a reduced holotrans-cobalamin 11 and transcobalamin II saturation. (The latter two tests are not commercially available.) Results of blood cell and deoxyuridine suppression tests are normal, as are levels of serum methylmalonic acid and homocysteine.
In the third stage, vitamin B12 deficient erythropoiesis, hyperseg-mented neutrophils appear, and the deoxyuridine suppression test becomes abnormal. The holotranscobalamin II and the transcobalamin II saturation fall further. The serum methylmalonic acid and homocysteine levels increase slightly. The patient is stilj not anemic, and the MCV is often normal. In the fourth stage, vitamin B12 deficiency anemia, all standard laboratory test results are abnormal, and the patient is anemic.
The stage at which myelin and brain damage occur is not known. Irreversible neurologic damage and dementia seem to occur before hypcrsegmentation develops and methylmalonic acid or homocysteine levels rise, so screening elderly persons for low serum vitamin B12 levels seems prudent. Because it is not known what proportion of cases will progress from the first to the fourth stage if untreated, treatment is currently recommended (see TABLE 71-4

Tags: and Stages, Signs, Symptoms

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