Vitamin B12 performs an essential function in DNA synthesis. Its deficiency is related to hematologic, neurologic, psychiatric, gastrointestinal, dermatologic, and cardiovascular manifestations. Vitamin B12 deficiency is a standard reason for megaloblastic anemia and pancytopenia. It has been implicated as a reason for peripheral neuropathy, subacute mixed degeneration of the spinal wire, ataxia, optic atrophy, psychosis, melancholy, and dementia.1 It’s a potential danger issue for thrombosis, myocardial infarction, and stroke.1
Cutaneous manifestations related to vitamin B12 deficiency are pores and skin hyperpigmentation, vitiligo, angular stomatitis, and hair modifications. A analysis of vitamin B12 deficiency is usually ignored in its early levels as a result of these indicators usually are not particular to vitamin B12 deficiency alone. There’s a paucity of reported circumstances of vitamin B12 deficiency the place mucocutaneous lesions predate different manifestations.
On this case report, we current 2 circumstances of vitamin B12 deficiency the place pores and skin lesions had been the one medical indicators, highlighting the next:
Case 1
A 34-year-old lady complained of pores and skin lesions that had developed on each her ft over the previous 1.5 months. She was a nonvegetarian. She was beneath the care of an endocrinologist for hyperthyroidism and was utilizing a 7.5-mg dose of carbimazole every day. On examination, she had nonitchy, hyperpigmented macular lesions predominantly on the dorsum of the center phalanges of the toes of each ft (Determine 1). There was no rash or dermatitis previous the onset of hyperpigmentation. This was her solely bodily signal.
Medical examination was in any other case unremarkable. There have been no medical options suggestive of autoimmune problems. The vitamin B12 stage was 113 pmol/L (regular vary 132 to 857 pmol/L). The total blood depend and imply corpuscular quantity had been inside regular limits (regular vary 80 to 97 fL). As there was no different trigger for the hyperpigmentation apart from a low serum vitamin B12 stage, she was began on intramuscular injections of 1000 μg of vitamin B12 adopted by a vitamin B advanced (nutritional vitamins B1, B6, and B12) pill every day. The vitamin B12 stage after therapy was 300 pmol/L. The hyperpigmented lesions improved inside 2 weeks of beginning therapy.
Case 2
A 54-year-old lady introduced with pores and skin lesions that she’d had on her neck and higher and decrease limbs for 4 months (Determine 2). Dietary historical past revealed that she was a lacto-vegetarian. She gave a historical past of seeing quite a few medical doctors, whose lotions and coverings for suspected dermatitis didn’t enhance her pores and skin lesions. She even made a video of her lesions and put it on the Web, hoping that any physician worldwide might assist her. On examination, the pores and skin lesions had been polymorphic and nonpigmented; they had been a number of, macular, maculopapular, and vesicular, involving the nape of neck, each elbows, each wrists, and each heels. Examination of the tongue, oral cavity, and central nervous system confirmed no abnormality.
The imply corpuscular quantity was 103 fL and the vitamin B12 stage was 100 pmol/L. Endoscopy of the abdomen confirmed proof of pangastritis. The affected person had optimistic check outcomes for parietal cell antibodies. Remedy with intramuscular injections of 1000 μg of vitamin B12 adopted by a vitamin B advanced (nutritional vitamins B1, B6, and B12) pill every day led to the entire disappearance of pores and skin lesions inside 1 month. The vitamin B12 stage after therapy was 189 pmol/L.
Dialogue
Vitamin B12 deficiency causes a spread of problems and impacts all age teams. The principle programs affected in vitamin B12 deficiency are the hematologic, gastrointestinal, and nervous programs.1 The mucocutaneous manifestations of vitamin B12 deficiency are much less frequent. In 1944, Dr Bramwell Prepare dinner first noticed that hyperpigmentation of the pores and skin was related to a macrocytic anemia and that each it and the anemia responded to crude liver extract.3
In sufferers with vitamin B12 deficiency, the next pores and skin lesions are reported: pores and skin hyperpigmentation, vitiligo, hair modifications, and recurrent angular stomatitis.4 Hyperpigmentation of the extremities—particularly over the dorsum of the arms and ft, with accentuation over the interphalangeal joints and terminal phalanges—related to pigmentation of oral mucosa is attribute of vitamin B12 deficiency.4 These indicators will be noticed in lots of different illnesses with or with out vitamin B12 deficiency. Baker et al reported a sequence of 21 sufferers with vitamin B12 deficiency who had hyper-pigmentation of the pores and skin.2
Aaron et al reported a sequence of 63 sufferers with vitamin B12 deficiency; 26 out of 63 (41%) sufferers had pores and skin and mucosal modifications.4 Glossitis (31%) was the most typical mucocutaneous manifestation, adopted by pores and skin hyperpigmentation (19%), hair modifications (9%), angular stomatitis (8%), and vitiligo (3%). The hyperpigmentation famous by Aaron et al was an essential basic examination discovering.4
The Case 1 affected person had hyperpigmentation over the dorsum of all of the toes, much like the kind of pigmentation described by Baker et al.2 There was no hyperpigmentation over palm creases and flexures. The hyperpigmentation associated to vitamin B12 deficiency is extra frequent in darker-skinned sufferers.
Few different circumstances of pores and skin hyperpigmentation as a result of vitamin B12 deficiency have been reported within the literature.5–9 The mechanism of hyperpigmentation is because of elevated melanin synthesis reasonably than a defect in melanin.10
In Case 2, the affected person had pores and skin lesions that weren’t pigmented. This was an uncommon presentation, differing from the sooner reported circumstances.2–4 She had optimistic check outcomes for parietal cell antibodies. The elevated macrocytic index and the dietary historical past had been the diagnostic clues on this affected person. Oral ulcers11 and vitiligo weren’t current in both of our circumstances.
Causes – “b vitamin deficiency rash”
The frequent reason for vitamin B12 deficiency is malabsorption.12 It takes 2 to five years to develop vitamin B12 deficiency, even within the presence of extreme malabsorption.13 Our sufferers didn’t have medical options suggestive of malabsorption.
A pores and skin biopsy, measurement of metabolites (equivalent to serum methyl malonic acid and homocysteine), and a Schilling check would have thrown extra mild on the analysis. The sufferers weren’t eager in getting the above assessments completed. Moreover, many of the assessments require referral to a tertiary hospital and can’t be completed within the ambulatory setting.
Vitamin B12 is current solely in animal meals, can’t be synthesized within the human physique, and should be provided within the weight loss program. Due to this fact, an in depth historical past of meals and dietary habits is required when evaluating pores and skin lesions.
Remedy
The therapy of vitamin B12 deficiency in pernicious anemia is 1000 μg of vitamin B12 by intramuscular injection every single day or each different day for 1 to 2 weeks, adopted by month-to-month injections for 3 months, and thereafter each 3 months for all times.1 Those that are poor for dietary causes will be maintained on oral cobalamin tablets after their course of vitamin B12 injections.
Conclusion
A affected person presenting with cutaneous lesions alone ought to make us extremely suspicious of the potential of vitamin B12 deficiency. We must be extra conscious that cutaneous lesions not responding to traditional remedy might very seemingly be a sign of vitamin B12 deficiency. These pores and skin manifestations reply shortly to vitamin B12 remedy. Early therapy with vitamin B12 will stop the intense issues of vitamin B12 deficiency.