Why did vitamin B12 deficiency respond to plasmapheresis ?
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Transcript of Why did vitamin B12 deficiency respond to plasmapheresis ?
WHY DID VITAMIN B12 DEFICIENCY RESPOND TO PLASMAPHERESIS?
J. Matthew Rhinewalt, MD, PGY-4
Internal Medicine/Pediatrics
University of MS Medical Center
Jackson, MS
Introduction
Vitamin B12 deficiency:Multi-organ dysfunctionVariety of clinical presentationsMay present clinically similar to thrombotic
thrombocytopenic purpura (TTP)
Case Description – History 62 y/o man
CC: confusionHPI:
○ 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
Case Description – Physical Exam Pertinent Physical Exam
Temperature 100.5°FWeight 185lbsSleepy/confusedJugular venous pressure 10cmLiver edge 3cm below right costal marginNo evidence of bleeding or petechiaeNegative bedside fecal occult blood testing
Case Description - Labs Pertinent (+) labs:
WBC 3.3Hgb 5Hct 15%MCV 108Plt 58,000Retic count 0.9%
(corrected)
LDH >2500haptoglobin <10total bilirubin 2.5
(indirect 1.7)Creatinine 1.6
(baseline 0.8)(baseline 0.7)
Case Description - Labs Pertinent (-/nrl) labs:
GlucoseUrine drug screenAlcohol levelCreatine kinaseTroponin
AmmoniaFecal occult blood
testingProthrombin time
Case Description - Labs Blood Smear:
Hypersegmented neutrophilsRare schistocytesMany tear drop cells
Moll. NEJM. 1996; 335:323. August 1, 1996.
Problems
Fever Hemolytic/Macrocytic Anemia Low Reticulocyte Count Thrombocytopenia Altered Mental Status Acute Kidney Injury History of Alcoholism, Type 2 Diabetes,
Seizure Disorder
Initial Differential Diagnosis#1 - Thrombotic Thrombocytopenic Purpura
#2 - Vitamin B12 Deficiency
#3 - Leukemia / Bone Marrow Malignancy
Management
Hematology consultPlasmapheresis for possible TTP
while awaiting labs
Therapy
4 units PRBC transfusion: hospital day 1 Plasmapheresis: hospital day 1-3
(12 bags FFP each treatment)
Results
Clinical improvement after first plasmapheresis:hemolysismental statusrenal function ADMIT HOSP DAY 2
LDH >2500 979
Haptoglobin <10 15
Bilirubin 3.4 2.6
Creatinine 1.6 0.98
Interesting Results
AdamTS13 activity normal Folate RBC level normal Leukemia/lymphoma panel normal
Vitamin B12 level 30pg/mL
(resulted on hospital day 3)
Continued Management
On hospital day 3:
Vitamin B12 1000mcg IM daily
Upon Discharge (Hospital Day 8)
PE: mental status back to baseline Labs:
Creatinine back to baselineHgb 10Platelet count 124,000Reticulocyte count 13% (corrected)LDH 777
Why did he rapidly improve with plasmapheresis?
How much vitamin B12 is in FFP?
Unable to locate a reference Is it degraded during processing?
Thank you to Dr. AsfourUMMC blood bank pathologistRandom sampling of 4 bags of FFP for
B12 levels○ Results: 300 – 500 pg/mL
Our patient’s level was 30 pg/mL
How much vitamin B12 is in FFP?
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
Thank You
Mohamed A. Asfour, MD Taylor Pruett, MD John C. Henegan, MD