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Haddad F, Boukhal Z, El Rhaoussi FZ, Tahiri M, Hliwa W, Bellabah A, Wafaa B. Neurological and Cardiovascular Complications Revealing Biermer's Disease: A Case Report. Cureus 2024; 16:e58601. [PMID: 38765343 PMCID: PMC11102770 DOI: 10.7759/cureus.58601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 05/22/2024] Open
Abstract
Biermer's disease (BD) or pernicious anemia (PA) is an autoimmune atrophic gastritis characterized by the absence of intrinsic factor (IF) secretion, leading to malabsorption of vitamin B12 in the ileum. Its clinical manifestations are primarily hematological, with neuropsychiatric and cardiovascular manifestations being less common. We present the case of a patient with PA diagnosed based on neurological and cardiovascular complications. The patient, a 56-year-old man with no specific medical history, presented with an episode of melena without other associated digestive symptoms. He also complained of memory and gait disturbances. Clinical examination revealed a cerebellar ataxia with impaired proprioceptive and vibratory sensitivity, and a swollen and red right lower limb with a positive Homan sign. The blood count showed macrocytic anemia. Gastroscopy revealed flattened fundic folds resembling a fundus appearance, and histopathological examination confirmed fundic atrophic gastritis with pseudopyloric metaplasia and lymphoplasmacytic infiltration. Anti-intrinsic factor antibodies were positive, while anti-parietal cell antibodies were negative. Vitamin B12 levels were severely low, and vitamin B9 levels were normal. TSH and HbA1c levels were within normal ranges. The abdominal CT scan showed no abnormalities. Lower limb Doppler ultrasound confirmed the diagnosis of deep vein thrombosis (DVT). Cardiac evaluation revealed sinus bradycardia suggestive of secondary dysautonomia. Therapeutically, the patient was started on vitamin B12 supplementation and anticoagulant therapy for DVT, resulting in a good clinical and biological outcome.
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Affiliation(s)
- Fouad Haddad
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
| | - Zineb Boukhal
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
| | - Fatima Zahra El Rhaoussi
- Faculty of Medicine and Pharmacy, Hassan II University, Casablanca, MAR
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
| | - Mohamed Tahiri
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
| | - Wafaa Hliwa
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
| | - Ahmed Bellabah
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
| | - Badre Wafaa
- Gastroenterology and Hepatology, Ibn Rochd University Hospital Center, Casablanca, MAR
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Esposito G, Dottori L, Pivetta G, Ligato I, Dilaghi E, Lahner E. Pernicious Anemia: The Hematological Presentation of a Multifaceted Disorder Caused by Cobalamin Deficiency. Nutrients 2022; 14:nu14081672. [PMID: 35458234 PMCID: PMC9030741 DOI: 10.3390/nu14081672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Pernicious anemia is still a neglected disorder in many medical contexts and is underdiagnosed in many patients. Pernicious anemia is linked to but different from autoimmune gastritis. Pernicious anemia occurs in a later stage of autoimmune atrophic gastritis when gastric intrinsic factor deficiency and consequent vitamin B12 deficiency may occur. The multifaceted nature of pernicious anemia is related to the important role of cobalamin, which, when deficient, may lead to several dysfunctions, and thus, the proteiform clinical presentations of pernicious anemia. Indeed, pernicious anemia may lead to potentially serious long-term complications related to micronutrient deficiencies and their consequences and the development of gastric cancer and type 1 gastric neuroendocrine tumors. When not recognized in a timely manner or when pernicious anemia is diagnosed with delay, these complications may be potentially life-threatening and sometimes irreversible. The current review aimed to focus on epidemiology, pathogenesis, and clinical presentations of pernicious anemia in an attempt to look beyond borders of medical specialties. It aimed to focus on micronutrient deficiencies besides the well-known vitamin B12 deficiency, the diagnostic approach for pernicious anemia, its long-term complications and optimal clinical management, and endoscopic surveillance of patients with pernicious anemia.
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Biron F, Rousseau JF, Baulin JM, Guérin-Boyer M, Lanéelle D. [Thromboembolic event and metabolic hyperhomocysteinemia: A case report and review of literature]. Ann Cardiol Angeiol (Paris) 2021; 70:177-182. [PMID: 33962786 DOI: 10.1016/j.ancard.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Venous thromboembolic diseases have an incidence of 1.57/1000. Among patients under 50 years old, thrombophilia is assessed, the indications for which are increasingly stringent. Today, the need of plasma homocysteine assay is uncertain. OBSERVATION Our case is a 42 year-old man, in whom a pulmonary embolism associated with macrocytosis made us discover a B12 deficiency secondary to Biermer's disease. In the literature, patients are men with an average age limit to the realisation of the assessment of thrombophilia. Not all of these patients had any causal other than hyperhomocysteinemia secondary to Biermer's disease. The support is not detailed. CONCLUSION Hyperhomocysteinemia is probably not the only thromboembolic factor. The patient received anticoagulation and vitamin B12 supplementation. A good reading of the complete blood count is essential.
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Affiliation(s)
- F Biron
- Service de cardiologie, CH de Falaise, Falaise, France; Service de médecine polyvalente, CH de Falaise, Falaise, France; Service de médecine vasculaire, CHU de Caen, Caen, France.
| | - J-F Rousseau
- Service de cardiologie, CH de Falaise, Falaise, France.
| | - J-M Baulin
- Service de médecine polyvalente, CH de Falaise, Falaise, France.
| | - M Guérin-Boyer
- Service de médecine polyvalente, CH de Falaise, Falaise, France.
| | - D Lanéelle
- Service de médecine vasculaire, CHU de Caen, Caen, France.
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Htut TW, Thein KZ, Oo TH. Pernicious anemia: Pathophysiology and diagnostic difficulties. J Evid Based Med 2021; 14:161-169. [PMID: 34015185 DOI: 10.1111/jebm.12435] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Abstract
Pernicious anemia (PA) is the most common cause of vitamin B12 (cobalamin) deficiency anemia in the world. It is an autoimmune disease, comprising of salient features of autoimmune chronic atrophic gastritis (CAG) and cobalamin deficiency (CD). Although the anemia was first described as pernicious, it may well be controlled with vitamin B12 replacement. The onset and progression of PA is often insidious. Alternatively, patients may have no anemic symptoms since they become acclimatized to the subtle nature of the disease. Oftentimes, there is a possibility that the underlying disease may be missed unless a full blood count (FBC) is investigated, leading to hindrance in the treatment journey. Diagnostic challenges remain tangible for many practicing clinicians, since there is lack of reliable cobalamin assays to diagnose CD as well as clinical mimics, which simulate many other hematological conditions, such as myelodysplastic syndrome, acute leukemia, sideroblastic anemias, bone marrow failure states, thrombotic microangiopathy, and thromboembolism. Moreover, prompt recognition of the symptoms of CD is also vital, because some neurologic sequalae may become irreversible despite replenishing cobalamin. Herein, we discuss a literature review on the pathophysiology, challenging clinical presentations and diagnostic difficulties of PA. Since the cobalamin replacement therapy for PA is straightforward, it will not be discussed in this review.
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Affiliation(s)
- Thura Win Htut
- Department of Hematology, Aberdeen Royal Infirmary Hospital, The University of Aberdeen, NHS Grampian, Scotland, UK
| | - Kyaw Zin Thein
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Thein Hlaing Oo
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, USA
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Leemann B, Boughanem N, Schnider A. L’accident ischémique cérébral, une complication rare de la maladie de Biermer. Rev Neurol (Paris) 2006; 162:1007-10. [PMID: 17028570 DOI: 10.1016/s0035-3787(06)75112-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Stroke in a young adult justifies an extensive etiologic workup. OBSERVATION We present a 44-year-old women victim of a frontal ischemic stroke. Extensive evaluation was normal, except for high plasma level of homocysteine in the context of pernicious anemia, otherwise asymptomatic. DISCUSSION Hyperhomocysteinemia is a known marker, and probably risk factor for stroke, fostering atherosclerosis and thrombosis. It can be found among individuals suffering from homocystinuria, in individuals homozygous for the MHTFR T allele but also when there is deficiency of vitamin B12 or folic acid. Although it is very seldom ascribed, pernicious anemia would be a cause of stroke, possibly though hyperhomocysteinemia.
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Affiliation(s)
- B Leemann
- Service de Rééducation, HUG, Switzerland.
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Barrios M, Alliot C. Venous thrombosis associated with pernicious anaemia. A report of two cases and review. ACTA ACUST UNITED AC 2006; 11:135-8. [PMID: 16753856 DOI: 10.1080/10245330500065763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Since homocystinuria, an inborn metabolism error is complicated by venous thrombosis in about half of the patients, hyperhomocysteinemia has been suspected of favouring thrombosis. Several case-control studies and even meta-analysis have confirmed a link between venous thrombosis and mild hyperhomocysteinemia. Nevertheless, the proper role of homocysteine remains debated. Hyperhomocysteinemia is induced by vitamin B9 or B12 deficiencies in a vast majority of cases. The authors report on two patients with venous thrombosis revealing pernicious anemia and review nine similar cases found in the world literature. The literature concerning the relationships between homocysteine and venous thrombosis is briefly reviewed.
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Affiliation(s)
- Marta Barrios
- Laboratory of Biology, Sud Leman-Valserine Hospital, avenue Amédée de Savoie, BP 110, 74164, Saint Julien en Genevoix Cedex, France
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Znazen R, Guermazi S, Karoui M. [Association of tow thrombotic risk factors: factor V Leiden and hyperhomocysteinemia. A case report]. ACTA ACUST UNITED AC 2006; 55:163-6. [PMID: 16707235 DOI: 10.1016/j.patbio.2006.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Accepted: 03/31/2006] [Indexed: 11/25/2022]
Abstract
The identification of constitutional and/or acquired risk factor is of major importance in the treatment of thromboembolic disease in young people; it contributes to evaluate the risk of recurrence and to define the period of oral prophylactic anticoagulant treatment. Several congenital or acquired abnormalities of haemostasis are actually defined. In this paper, we report the case of a 34-year-old man who developed a deep venous thrombosis, five months before the diagnosis of megaloblastic anemia, probably due to pernicious anemia. The thrombosis was partially explained by the acquired hyperhomocysteinemia induced by vitamin B12 deficiency. Moreover, activated protein C resistance due to factor V Leiden, was revealed in our patient. This latter improved under anticoagulant treatment combined with vitamin B12. Combination in one individual, of different risk factors predisposing to inherited and/or acquired thrombophilia, results in increased risk for thrombo-embolic disease, suggesting synergic interaction between these factors.
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Affiliation(s)
- R Znazen
- Laboratoire d'hématologie, banque du sang, hôpital Charles-Nicolle, Bab-Bnet boulevard 9 avril, Tunis 1006, Tunisie.
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Fernández-Miranda C, Yebra Yebra M, Ribera Casado C, Toledo Urgarte T, Martín Mola M, Gómez González P. Tromboembolia venosa e hiperhomocisteinemia como primera manifestación de una anemia perniciosa. Rev Clin Esp 2005; 205:489-92. [PMID: 16238959 DOI: 10.1157/13079763] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION AND OBJECTIVE Hyperhomocysteinemia is associated to thrombosis and atherosclerosis. Vitamin B12 is among its main causes and may be due to a pernicious anemia. This study aimed to know the prevalence of this disease in patients who have venous thromboembolism and hyperhomocysteinemia. PATIENTS AND METHODS A total of 80 consecutive patients (55 men and 25 women; age: mean [standard deviation] 63 [15] years) with pulmonary embolism and/or venous thrombosis and elevated values of homocysteine (> 12 micromol/l) were studied. RESULTS Pernicious anemia was diagnosed (positive Schilling test, presence of anti-intrinsic factor antibodies and/or anti-parietal cells and fundal atrophic gastritis) in 5 patients (6.25% with range of age: 42-73 years. Only one of them had macrocytic anemia and there were no alterations in any of them in the thrombophilia study. The patients were treated with vitamin B12, administering it orally (1 mg/day) in 4 of them. The homocysteine and vitamin B12 values were normalized in every case at 6 months. CONCLUSIONS Although the prevalence of pernicious anemia is not elevated in patients with venous thromboembolism and hyperhomocysteinemia, its existence must be ruled out to avoid other thrombotic and neurological complications.
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