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A 59-year-old male with no reported past medical history presents with complaints of progressive weakness, lethargy, dysthymic mood, bilateral feet tingling, and an estimated 30 pounds weight loss over the course of the last year. Additionally, the patient reports that during the course of the last year he had been having an increasingly difficult time performing daily workplace responsibilities due to progressive generalized weakness. He also complained of lightheadedness and nausea after prolonged standing which improved with rest. The patient visited his primary care physician for progressive symptoms and found to be severely anemic. He was then referred to the hospital for further evaluation and possible blood transfusion. In the emergency department (ED), his vital signs were temperature of 97.8 degrees Fahrenheit, respiratory rate of 14 breaths/minute, heart rate of 94 beat/ minute, blood pressure of 168/68 mmHg, and pulse oximetry of 98% on ambient air. The physical examination showed mucosal and conjunctival pallor, no scleral icterus, no palpable lymph nodes, nondistended abdomen, normal bowel sound with no organomegaly, unremarkable cardio and lung examination, and decreased pin prick and vibratory sensation on bilateral lower extremities. Initial laboratory studies revealed white blood cell count (WBC) of 3.1 k/ul (4.5-11 k/ul) with an absolute neutrophil count (ANC) 1.6 × 103/ul, hemoglobin (Hgb) 5.0 gm/dl (13.2-17.5 gm/dl), hematocrit (Hct) 14.4% (40-53%), platelets 137 k/ul (140-450 k/ul), and a mean corpuscular volume (MCV) 130.9 fl (80-100 fl). Liver function tests showed alkaline phosphate 139 U/L, aspartate aminotransferase 156 U/L (reference range 5-34 U/L), alanine aminotransferase 96 U/L (10-40 U/L), and total bilirubin of 4 mg/dl. Both a liver ultrasound and an abdominal computerized tomography (CT) scan were unremarkable. Additional laboratory investigation revealed very low vitamin B12 level of 52 pg/ml (200-900 pg/ml), markedly elevated lactate dehydrogenase (LDH)>2700 U/L, undetectable haptoglobin

The patient was transfused 2 units of packed red blood cells in the ED and 1000 mcg intramuscular vitamin B12 daily was initiated, with the hemoglobin responding appropriately. On hospital day two, the patient underwent an esophagogastroduodenoscopy which showed no evidence of upper gastrointestinal source of bleeding or autoimmune erosive gastritis. Given the patients’ laboratory and clinical features a diagnosis of hemolytic anemia secondary to severe vitamin B12 deficiency was made. He was continued on vitamin B12 injections, and monitored in the hospital for an additional 24 h. The patient’s initial symptoms of lethargy, weakness, dysthymia, and bilateral sensory loss of his feet improved significantly, and his hemoglobin was stable at 10.3 gm/dl at the time of discharge.

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