A 76-year-old woman with a medical history of 3 to 4 months gradually increased tiredness and lethargy. 

She also noticed numbness and tingling in her hands. 

Upon examination, she was pale and slightly jaundiced. A skin rash appears. 

Sensory tests on the legs showed decreased sensation, affecting the feet symmetrically. 

Neither ankle jerks exist and brisk the knee jerks. 

Hemoglobin (Hb) 65 g/L 

Mean corpuscular volume (MCV) 110 fL 

White blood cells (WBC) 2.5 X 109/L 

Platelets 103 X 109/L 

Q1. What is the dermatological diagnosis? 

 

Q2. What is the hematological diagnosis? What abnormalities are shown on the blood film? 

Q5. How should the patient be treated? 

A1. Vitiligo. This is related to organ-specific autoimmune diseases, for example: 

- Pernicious anemia 

- Thyroid disease 

- Addison’s disease 

- Hypoparathyroidism 

A2. Pernicious anemia (PA). The blood smear shows macrocytosis, anisocytosis, and hypersegmented polymorphonuclear leukocytes. 

There is also a circulating megaloblast. 

The deficiency of vitamin B12 is due to the failure of the absorption of the vitamin to the stomach. 

Antibodies to gastric parietal cells are present in 95% of patients with pernicious anemia but only 10% of normal individuals. 

Antibodies to intrinsic factor are found in 60% of people with pernicious anemia. 

A3. Subacute combined degeneration of the spinal cord, with a characteristic combination of upper and lower motor neuron signs in the legs. 

A4. The following investigations should be carried out: 

- Serum B12 

- Serum folate and ferritin, and red blood cell folate (in B12 deficiency, elevated red blood cell folate, and decreased serum folate are typical). 

- Thyroid-stimulating hormone (TSH) level 

- An upper gastrointestinal endoscopy is advised. 

A5. Administration of folic acid without B12 therapy can lead to worsening of the neurological changes. 

B12 is the coenzyme of methionine synthase, which is a reaction Folic acid is activated by converting it from methyltetrahydrofolate (me-THF) to THF. 

The reaction is related to the demethylation of methionine to homocysteine and emphasizes the role of B12 and folate metabolism in reducing homocysteine ​​levels and improving the risk of cardiovascular disease. 

Folic acid is a coenzyme that synthesizes thymidine monophosphate (TMP); therefore, lack of B12 and folic acid can lead to impaired DNA synthesis. 

Parenteral B12-1000 mg of hydroxocobalamin is injected intramuscularly every week for 4 weeks, and then long-term injections every 3 months. 

Iron and folic acid supplements should be taken orally during the first two months of treatment. 

The image below shows pallor with mild jaundice in a woman with PA who has dyed her hair (premature greying is characteristic). 

The figure below shows her fleshy tongue. 

The incidence of gastric cancer in these patients has increased.