Alternate Names: Addison's anemia; Biermer's anemia; Macrocytic achylic anemia; Congenital pernicious anemia; Juvenile pernicious anemia; Vitamin B12 deficiency (malabsorption)

Causes and Risks:

Intrinsic factor is a binding protein required for the absorption of vitamin B12. Pernicious anemia results from a lack of intrinsic factor in gastric secretions which, in turn, causes inadequate vitamin B12 absorption. Vitamin B12 deficiency is the result. The vitamin B12 deficiency causes a form of anemia specifically referred to as megaloblastic anemia.

Other causes of pernicious anemia include atrophic gastric mucosa, autoimmunity against gastric parietal cells, and autoimmunity against instrinsic factor.

A lack of intrinsic factor is the most common cause of vitamin B12 deficiency. Intrinsic factor is produced by cells within the stomach. In adults, the inability to make intrinsic factor is the result of chronic gastritis or is the result of gastrectomy. The onset of the disease is slow and may span decades. Very rarely, infants and children lack the ability to produce effective intrinsic factor. This form of congenital pernicious anemia is inherited as an autosomal recessive disorder. However, most often, megaloblastic anemia in children results from other causes of vitamin B12 deficiency or other vitamin deficiencies.

Although a juvenile form of the disease can occur in children, pernicious anemia usually does not appear before the age of 30. The average age at diagnosis is 60 years. In fact, one recent study revealed that nearly 2 percent of individuals over 60 years old suffer from pernicious anemia. Furthermore, slightly more women than men are affected. The disease can affect all racial groups, but the incidence is higher among people of Scandinavian or Northern European descent.

Risk factors include a family history of pernicious anemia, Scandinavian or Northern European descent, and a history of autoimmune endocrine disorders. Pernicious anemia is seen in association with some autoimmune endocrine diseases such as type 1 diabetes, hypoparathyroidism, Addison’s disease, hypopituitarism, testicular dysfunction, Graves disease, chronic thyroiditis, myasthenia gravis, secondary amenorrhea, and vitiligo.

In addition to pernicious anemia, other causes of Vitamin B12 Deficiency include:

• nutrition (strict vegetarians without B12 supplementation, poor diet in infant or poor maternal nutrition during pregnancy)
• infection (intestinal parasites, bacterial overgrowth)
• gastrointestinal disease (surgical resection, celiac disease (sprue), Crohn’s disease)
• drugs (colchicine, neomycin, tuberculosis treatment with para amino salicylic acid)
• metabolic disorders (methylmalonic aciduria, homocystinuria)

Prevention:

This condition is not preventable, but with early detection and treatment pernicious anemia and its complications are readily controlled.

Symptoms:

Gradually the deficiency of vitamin B12 affects sensory and motor nerves, causing neurological effects. It is important to know that the neurological effects of vitamin B12 deficiency may present before anemia is diagnosed. The anemia also affects the gastrointestinal system and the cardiovascular system. The following symptoms may indicate pernicious anemia:

• shortness of breath
• fatigue
• pallor
• rapid heart rate
• loss of appetite
• diarrhea
• tingling and numbness of hands and feet (paresthesias)
• sore mouth
• unsteady gait, especially in the dark
• tongue problems
• smell, impaired
• gums, bleeding
• positive Babinski’s reflex
• loss of deep tendon reflexes
• personality changes ("megaloblastic madness")

Signs and Tests:

Tests that may indicate pernicious anemia include:

• CBC results that show low hematocrit and hemoglobin with elevated MCV (low red blood cell count with large-sized red blood cells)
• CBC showing low white blood count and low platelets
• low reticulocyte count
• bone marrow examination (only needed if diagnosis is unclear)
• serum LDH
• below normal serum vitamin B-12 level
• Schilling test
• measurement of serum holotranscobalamin II

This disease may also alter the results of the following tests:

• TIBC
• peripheral smear
• leukocyte alkaline phosphatase
• gastrin
• cholesterol test
• bilirubin

Treatment:

Monthly Vitamin B12 injections are the definitive treatment to correct the vitamin B12 deficiency. This therapy corrects the anemia and may correct the neurological complications if given soon enough. Since about 1 percent of vitamin B12 is absorbed even in the absence of intrinsic factor, some doctors recommend elderly patients with gastric atrophy to take oral vitamin B12 supplements in addition to monthly injections. There is also a preparation of vitamin B12 that may be given intranasally (in the nose). A well-balanced diet is essential to provide other elements such as folic acid, iron, and vitamin C for healthy blood cell development.

Prognosis:

The outcome is usually excellent with treatment.

Complications:

• People with pernicious anemia may have gastric polyps and have twice the incidence of gastric cancer than the normal population.
• Persistent neurological defects may be present if treatment is delayed.
• Vitamin B12 deficiency affects the appearance of all epithelial cells, therefore an untreated woman may obtain a false positive pap smear.

Call for an appointment with your health care provider if symptoms of pernicious anemia develop.