J Rheum Dis.  2015 Oct;22(5):327-331. 10.4078/jrd.2015.22.5.327.

Central Nervous System Complication due to Pernicious Anemia in a Patient with Rheumatoid Arthritis

• Lee JM
• Chai JW
• Shin K

• KMID: 2222848
• DOI: http://doi.org/10.4078/jrd.2015.22.5.327

Abstract

Pernicious anemia (PA) is an autoimmune disease characterized by atrophic gastritis and deficiency in intrinsic factor leading to impairment of vitamin B12 absorption in the ileum. Anemia is commonly found in rheumatoid arthritis (RA); however, PA is rarely found in RA. There are few reports describing patients with both conditions; none in Korea to date. We report on a case of a 46-year-old female who presented with hypesthesia and general weakness. She was previously diagnosed as seropositive RA with myelodysplastic syndrome. She had severely impaired sensation, especially for vibration and proprioception in all limbs. Subacute combined degeneration was observed on her magnetic resonance imaging and serum vitamin B12 level was very low. Further exam results were consistent with PA and her symptoms improved with cobalamin injection. This case demonstrates that PA should be considered in RA patients presenting with both central nervous system manifestations and anemia.

Keyword

Pernicious anemia; Rheumatoid arthritis; Vitamin B12

MeSH Terms

Absorption
Anemia
Anemia, Pernicious*
Arthritis, Rheumatoid*
Autoimmune Diseases
Central Nervous System*
Extremities
Female
Gastritis, Atrophic
Humans
Hypesthesia
Ileum
Intrinsic Factor
Korea
Magnetic Resonance Imaging
Middle Aged
Myelodysplastic Syndromes
Proprioception
Subacute Combined Degeneration
Vibration
Vitamin B 12
Intrinsic Factor
Vitamin B 12

Figure

• 

  Figure 1. Posterior tibial nerve somatosensory evoked potential of the patient showed normal absolute latencies in both TN1, LN1, but P1 wave was absent on both sides, which indicates central conduction defect of the thoracic spinal cord. Median nerve somatosensory evoked potentials were normal, which demonstrates normal sensory pathways above the cervical spinal cord. ASIS: anterior superior iliac spine.

• 

  Figure 2. Magnetic resonance imaging study of the spinal cord showing demyelination involving dorsal columns of the spinal cord from T9 to L1 shown as a linear high intensity signal (arrows) on the T2-weighted image.

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  Figure 3. Atrophic mucosal changes in gastric antrum and body.

Reference

1. Bizzaro N, Antico A. Diagnosis and classification of pernicious anemia. Autoimmun Rev. 2014; 13:565–8.

2. Song IC, Lee HJ, Kim HJ, Bae SB, Lee KT, Yang YJ, et al. A multicenter retrospective analysis of the clinical features of pernicious anemia in a Korean population. J Korean Med Sci. 2013; 28:200–4.

3. Korean Neurological Association. Textbook of neurology. 2th ed.Seoul: Beommun Education;2012. p. 650–1.

4. Drabick JJ, Davis BJ, Byrd JC. Concurrent pernicious anemia and myelodysplastic syndrome. Ann Hematol. 2001; 80:243–5.

5. Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med. 1999; 159:1289–98.

6. Carmel R, Agrawal YP. Failures of cobalamin assays in pernicious anemia. N Engl J Med. 2012; 367:385–6.

7. Nam EJ, Kang YM, Kang HR, Kim JH, Rho HJ, Lee MK, et al. Rheumatoid arthritis associated with myelodysplastic syndrome: a case report. J Korean Med Sci. 1999; 14:319–22.

8. Partridge RE, Duthie JJ. Incidence of macrocytic anaemia in rheumatoid arthritis. Br Med J. 1963; 1:89–91.

9. Bieder L, Wigley RD. Vitamin B12 deficiency in rheumatoid arthritis. A study of haematological and neuropsychiatric changes. N Z Med J. 1964; 63:375–8.

10. Carter ME, Ardeman S, Winocour V, Perry J, Chanarin I. Rheumatoid arthritis and pernicious anaemia. Ann Rheum Dis. 1968; 27:454–6.

11. Pitcher CS, Lindsay DJ, Hill AG. Absorption of vitamin B12 in rheumatoid arthritis. Ann Rheum Dis. 1970; 29:533–6.

12. Ghazi HA. Pernicious anaemia and rheumatoid arthritis. Br Med J. 1972; 1:144–5.

13. Abraham Z, Rozenbaum M, Glück Z, Feuerman EJ, Lahat N, Kinarty A. Vitiligo, rheumatoid arthritis and pernicious anemia. J Dermatol. 1993; 20:418–23.

14. Wang PL, Liou LB, Dunn P. Development of rheumatoid arthritis in a patient with pernicious anemia: case report. Chang Gung Med J. 2001; 24:125–9.