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