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Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 89-92

When the picture is fragmented: Vitamin B12deficiency masquerading as thrombotic thrombocytopenic purpura

1 Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
2 Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
3 Department of Medicine, Division of Hematology-Oncology, James Graham Brown Cancer Center, School of Medicine, University of Louisville, Louisville, KY, USA
4 Department of Medicine, Division of General Internal Medicine, Palliative Medicine and Medical Education, School of Medicine, University of Louisville, Louisville, KY, USA

Correspondence Address:
Tanmay S Panchabhai
Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Suite 500, Phoenix, AZ
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5151.183026

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Thrombotic thrombocytopenic purpura (TTP) has high mortality and necessitates prompt recognition of microangiopathic hemolytic anemia (MAHA) and initiation of plasmapheresis. We present a challenging diagnostic workup and management of a 42-year-old man who presented with anemia, thrombocytopenia, and schistocytes on peripheral smear, all pointing to MAHA. Plasmapheresis and steroid therapy were promptly initiated, but hemolysis continued. Further workup showed megaloblastic anemia, severe Vitamin B12deficiency, high iron saturation, and absent reticulocytosis, none of which could be explained by TTP. Severe Vitamin B12deficiency can lead to hemolytic anemia from the destruction of red cells in the marrow that have failed the process of maturation. However, this should not cause thrombotic microangiopathy. Previous reports of B12deficiency presenting with MAHA and a TTP-like manifestation have identified acute hyperhomocysteinemia as a missing link between B12deficiency and MAHA, so this possibility was further explored. Our patient similarly had significantly elevated serum homocysteine levels, confirming this suspicion of Vitamin B12deficiency. Vitamin B12replacement led to normalization of the elevated levels of homocysteine, the disappearance of schistocytes on the peripheral smear, and resolution of the microangiopathic hemolysis, thereby confirming the diagnosis. It is pertinent that intensivists not only know the importance of early recognition and treatment of TTP but are also familiar with rare conditions that can present in a similar fashion.

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