![]() Serum parietal cell antibody test was positive and intrinsic factor blocking antibody was elevated at 173.1 AU/mL (reference range: 0.0-0.1 AU/mL), diagnostic of pernicious anemia. Urine methylmalonic acid was elevated at 15,100 micromole/L (reference range 1.6-29.7). In order to determine the etiology, homocysteine and methylmalonic acid levels were ordered. The low vitamin B12 level and the findings on the blood smear are consistent with vitamin B12 deficiency. Platelets were normal in number and morphology with the exception of a few large platelets. WBC morphology was overall normal, with rare hypersegmented neutrophils. Occasional schistocytes, rare basket cells and nucleated red blood cells were also noted. Review of the blood smear showed red blood cell morphology with significant anisocytosis, macro-ovalocyts and tear drop cells. B12 level was low at 142 pg/mL (reference range 211-911) while folate levels were within normal limits. To further evaluate the macrocytic anemia, serum and red blood cell folate and B12 level were obtained. An abdominal ultrasonography and chest radiograph are normal. The total serum bilirubin is 4.1 mg/dL with direct fraction of 0.2 mg/dL. Liver enzymes and serum uric acid are within normal limits. Serum lactate dehydrogenase is elevated to 2,057 units/L. There is no lymphadenopathy, hepatosplenomegaly, petechiae, bruising or ecchymosis noted.ĭiagnostic studies obtained show a hemoglobin of 6.8 gm/dL, hematocrit of 20.3%, MCV 106.3 FL, RDW 22/9%, reticulocyte count of 1.3%, a white blood cell count (WBC) of 3.8 K/CUMM, an absolute neutrophil count of 1824 K/CUMM and a normal platelet count. Physical examination is significant for scleral icterus with pallor of the conjunctiva and nail beds and mild tachycardia. Vitals on presentation to the ER are as follows: BP: 110/68 mmHg, HR 100 bpm, RR 22 brpm, temp 37.1☌, Ht 157cm, Wt 38 kg, BMI 15.4 kg/m 2 (16 th%ile). Family history is significant for anemia, rheumatoid arthritis, Cohn's disease, fibromyalgia, pulmonary embolism, heart disease and hypertension. ![]() Her past medical history is significant for intermittent asthma, eczema, seasonal allergies and cataract of the left eye. Today she had a syncopal episode that lasted a few minutes without any seizure like activity. Mom noticed yellowing of the eyes and pallor of the palms of the hands for the last two weeks. She has a 6 week history of vague symptoms including decreased appetite, dizziness, fatigue and weakness. A 12-year-old African American adolescent girl presents to the Emergency Department with the chief complaint of dizziness. ![]()
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