Monday Pharmaceutical Mystery: February 4

One of your regular customers comes into the pharmacy in a wheelchair. You ask him what happened, since last month he looked completely healthy. You know him well, he’s a middle-aged man who requires gluten free pills. He has chronic anemia, secondary to celiac disease and started receiving iron infusions about 6 months ago because oral iron never corrected the anemia, due to malabsorption issues.

He explains how the numbness in his fingers (that he thought was carpal tunnel syndrome) started to spread to the point that he was unable to walk. He has back pain that radiates down his legs and his legs are too weak to support him. He said he had an MRI on his spine and the doctors said he is not a candidate for surgery because his vertebra and discs are in prefect alignment. He was sent to a spinal specialist who injected cortisone around the spinal area, and that did nothing.

Mystery: Why is this person having progressive weakness and lower extremity pain unrelieved by steroid injections?

Solutions: The iron infusions triggered it. The building blocks for red blood cells are iron, folic acid, and vitamin B12. Vitamin B12 is also needed for nerve function. The patient was already low on vitamin B12 due to malabsorption, then the newly forming red blood cells stole the much needed B12 vitamin from the nerves to make red blood cells. Severe vitamin B12 deficiencies are rare and manifest in neuropathies.

(This mystery is based on a true story, and fortunately the vitamin B12 supplements reversed the patient's neuropathies to the point that where he now walks with a limp, but is no longer confined to a wheelchair.)

Reference

Ekabe CJ, Kehbila J, Abanda MH, et al. Vitamin B12 deficiency neuropathy; a rare diagnosis in young adults: a case report. BMC Research Notes vol. 10,1 72. 28 Jan. 2017, doi:10.1186/s13104-017-2393-3