Primary Neurologic Symptoms: Have You Considered Pernicious Anemia?

BACKGROUND: Vitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. CASE REPORT: A 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.

Esophageal Obstruction and Death in a Nonverbal Patient.

BACKGROUND: There are more than 100,000 cases of esophageal foreign body in the United States each year. Most cases resolve spontaneously; however, complete esophageal obstruction is a medical emergency. Patients with developmental disabilities are at high risk, because a large percentage of this population is effected by dysphagia, pica, tooth loss, or impulsive swallowing. In some cases, the diagnosis of esophageal foreign body can be made clinically, with the typical presentation including coughing, inability to tolerate secretions, drooling, vomiting, and dysphagia. In other instances, imaging is needed to confirm the diagnosis. CASE REPORT: A nonverbal adult patient with history of mental retardation and dysphagia presented to the emergency department (ED) after a choking episode with persistent coughing. An x-ray study of the chest showed mild opacity at the left lung base and she was discharged with antibiotics. She returned to the ED that day with worsening symptoms suggestive of aspiration pneumonia. A computed tomography scan of the chest revealed numerous cylindrical objects in the esophagus, later identified as crayons. At least 28 crayons were removed via 3 endoscopies. During this time, the patient developed aspiration pneumonia, respiratory distress, and septic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Delayed recognition of foreign body puts patients at risk for esophageal perforation, aspiration, airway compromise, infection, sepsis, and death. In nonverbal patients presenting with upper respiratory symptoms, it is especially important to consider esophageal foreign body in the differential diagnosis, because this group is high risk for missed diagnosis and complications secondary to the foreign body.