“I’m Tired” (continued)

Further labwork:

  • LDH elevated at 1500, Haptoglobin low at <10
    • This led to a suspicion for hemolytic anemia
  • Vitamin B12 low at 67 pg/mL
    • Unexplained by dietary intake
  • Folate within normal limits
  • Peripheral smear showed 1+ schistocytes

A direct antiglobulin test returned positive for a warm IgG antibody. This explained, in part, her hemolytic anemia (though a low vitamin B12 level can also cause a hemolytic anemia). However, it did not explain why she would have a low B12 level. HIV, viral hepatitis, CMV, EBV, and an ANA all returned negative.

She required 1 unit of packed red blood cells on day 2 of hospitalization for a hemoglobin < 7.

She was supplemented with IM vitamin B12 and started on prednisone 1mg/kg qday, and within 3 days her reticulocyte count rebounded to 14%.

Anti-parietal and anti-intrinsic factor antibodies were obtained before discharge, and the anti-intrinsic factor returned positive, suggesting an element of pernicious anemia, explaining the low B12 level.

For more, see Anemia

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