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Why did vitamin B12 deficiency respond to plasmapheresis ?

J. Matthew Rhinewalt , MD, PGY-4 Internal Medicine/Pediatrics University of MS Medical Center Jackson, MS. Why did vitamin B12 deficiency respond to plasmapheresis ?. Introduction. Vitamin B12 deficiency: Multi-organ dysfunction Variety of clinical presentations

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Why did vitamin B12 deficiency respond to plasmapheresis ?

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  1. J. Matthew Rhinewalt, MD, PGY-4 Internal Medicine/Pediatrics University of MS Medical Center Jackson, MS Why did vitamin B12 deficiency respond to plasmapheresis?

  2. Introduction • Vitamin B12 deficiency: • Multi-organ dysfunction • Variety of clinical presentations • May present clinically similar to thrombotic thrombocytopenic purpura (TTP)

  3. Case Description – History • 62 y/o man • CC: confusion • HPI: • 3 days of confusion per emergency medical personnel • pt unable to answer any questions upon presentation and no family present • PMH: type 2 diabetes, seizure disorder, alcoholism, illicit drug use

  4. Case Description – Physical Exam • Pertinent Physical Exam • Temperature 100.5°F • Weight 185lbs • Sleepy/confused • Jugular venous pressure 10cm • Liver edge 3cm below right costal margin • No evidence of bleeding or petechiae • Negative bedside fecal occult blood testing

  5. Case Description - Labs • Pertinent (+) labs: • WBC 3.3 • Hgb 5 • Hct 15% • MCV 108 • Plt 58,000 • Retic count 0.9% (corrected) • LDH >2500 • haptoglobin <10 • total bilirubin 2.5 (indirect 1.7) • Creatinine 1.6 (baseline 0.8)(baseline 0.7)

  6. Case Description - Labs • Pertinent (-/nrl) labs: • Glucose • Urine drug screen • Alcohol level • Creatine kinase • Troponin • Ammonia • Fecal occult blood testing • Prothrombin time

  7. Case Description - Labs • Blood Smear: • Hypersegmented neutrophils • Rare schistocytes • Many tear drop cells Moll. NEJM. 1996; 335:323. August 1, 1996.

  8. Problems • Fever • Hemolytic/Macrocytic Anemia • Low Reticulocyte Count • Thrombocytopenia • Altered Mental Status • Acute Kidney Injury • History of Alcoholism, Type 2 Diabetes, Seizure Disorder

  9. Initial Differential Diagnosis #1 - Thrombotic Thrombocytopenic Purpura #2 - Vitamin B12 Deficiency #3 - Leukemia / Bone Marrow Malignancy

  10. Management • Hematology consult • Plasmapheresis for possible TTP while awaiting labs

  11. Therapy • 4 units PRBC transfusion: hospital day 1 • Plasmapheresis: hospital day 1-3 (12 bags FFP each treatment)

  12. Results • Clinical improvement after first plasmapheresis: • hemolysis • mental status • renal function

  13. Interesting Results • AdamTS13 activity normal • Folate RBC level normal • Leukemia/lymphoma panel normal • Vitamin B12 level 30pg/mL (resulted on hospital day 3)

  14. Continued Management • On hospital day 3: Vitamin B12 1000mcg IM daily

  15. Upon Discharge (Hospital Day 8) • PE: mental status back to baseline • Labs: • Creatinine back to baseline • Hgb 10 • Platelet count 124,000 • Reticulocyte count 13% (corrected) • LDH 777

  16. Why did he rapidly improve with plasmapheresis?

  17. How much vitamin B12 is in FFP? • Unable to locate a reference • Is it degraded during processing?

  18. How much vitamin B12 is in FFP? • Thank you to Dr. Asfour • UMMC blood bank pathologist • Random sampling of 4 bags of FFP for B12 levels • Results: 300 – 500 pg/mL • Our patient’s level was 30 pg/mL

  19. Clinical Impact • Vitamin B12 levels in FFP were comparable to serum levels of non-deficient patients • need for baseline B12 level • signs & symptoms of vitamin B12 deficiency may likely improve if given FFP

  20. Thank You • Mohamed A. Asfour, MD • Taylor Pruett, MD • John C. Henegan, MD

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