Case 13-2012 — A 62-Year-Old Man with Paresthesias, Weight Loss, Jaundice, and AnemiaOn examination, the patient appeared pale. The temperature was 37.5°C, the blood pressure 136/63 mm Hg, the pulse 113 beats per minute, the respiratory rate 20 breaths per minute, and the oxygen saturation 99% while he was breathing ambient air. The tongue was swollen and smooth, the conjunctivae were pale and icteric, and the palate, subglossal mucosa, and skin were jaundiced. The abdomen was soft, with mild-to-moderate tenderness in the epigastrium, without rebound, guarding, organomegaly, or masses. On neurologic examination, there was pronator drift bilaterally. Sensation to light touch was decreased by approximately 80% in the hands and feet; sensation to vibration and temperature was decreased in both legs in a “stocking” pattern and was normal in both arms. A Romberg test was positive, with swaying and falling when the patient's eyes were closed; toe, heel, and heel-to-toe gaits were normal. Muscle strength, reflexes, and the remainder of the examination were normal. The blood level of potassium was 3.2 mmol per liter (reference range, 3.4 to 4.8) and globulin 2.1 g per deciliter (reference range, 2.3 to 4.1). Blood levels of the other electrolytes, glucose, calcium, phosphorus, magnesium, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, amylase, lipase, total protein, and albumin were normal, as were tests of renal function; tests for creatine kinase isoenzymes and troponin I were negative, and other test results are shown in Table 1TABLE 1
. An electrocardiogram was normal. A chest radiograph showed degenerative changes of the thoracic spine and was otherwise normal. A stool specimen was negative for occult blood. One liter of crystalloid solution was administered intravenously, with improvement in the tachycardia. Three hours after presentation, the patient was admitted to this hospital; 2 units of red cells were transfused. Paresthesias involve a sensation of tingling, numbness, crawling, or deadness, and they are felt mainly in distal parts of the extremities. Although on rare occasions they can involve the thalamus, paresthesias are mostly considered to originate from a spinal cord disorder that probably results from ectopic discharge in damaged dorsal-column axons and may be present before any other abnormalities are detectable on neurologic examination.Table 2 Although there are many possible causes of paresthesias (TABLE 2 ), most are not considerations in this case. The list of possible causes of sensory ataxia is limited (Table 3TABLE 3 ). On the basis of what we know from this patient's clinical presentation and history, we can safely rule out hereditary ataxias, sensory polyneuropathies, and multisystem atrophy. Dr. Anand S. Dighe: A peripheral-blood smear showed anisocytosis with oval macrocytes and abundant neutrophil hypersegmentation; no schistocytes or spherocytes were present (Figure 1FIGURE 1 ). Anemia studies were obtained. The level of vitamin B12 was very low at 61 pg per milliliter (45 pmol per liter) (reference range, >250 pg per milliliter [>185 pmol per liter]) and the level of folate was normal at 17.2 ng per milliliter (38.9 nmol per liter) (reference range, 3.1 to 17.5 ng per milliliter [70.5 to 39.7 nmol per liter]). Iron studies revealed a low serum iron level of 19 μg per deciliter (3 μmol per liter) (reference range, 45 to 160 μg per deciliter [8 to 29 μmol per liter]), a slightly low total iron-binding capacity of 221 μg per deciliter (40 μmol per liter) (reference range, 230 to 404 μg per deciliter [41 to 72 μmol per liter]), and an elevated ferritin level of 340 ng per milliliter (reference range for men, 30 to 300). The calculated transferrin saturation (calculated as the level of iron divided by the total iron-binding capacity) was 8.6%, suggestive of iron deficiency. It is well described that iron deficiency and elevated ferritin levels may develop in patients with pernicious anemia. Dr. Mari Mino-Kenudson: Patients with pernicious anemia have an increased risk of gastric carcinoma and carcinoid tumors.Figure 2A and 2B The patient underwent endoscopy to evaluate the upper and lower gastrointestinal tract to assess for a neoplastic condition and to rule out gastrointestinal bleeding as a possible contributor to the patient's iron deficiency. The mucosal surfaces of the gastric fundus and body appeared atrophic, and histologic sampling confirmed mucosal atrophy with pseudopyloric and intestinal metaplasia, consistent with autoimmune gastritis. No evidence of gastric carcinoma or carcinoid was present (FIGURE 2 ). The remainder of the endoscopic evaluation was unremarkable. The role of H. pylori in the pathogenesis of pernicious anemia is an area of active investigation. The patient was assessed for the presence of H. pylori; bothH. pylori IgG serologic tests and stool antigen tests were negative.