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Generalised hyperpigmentation in Vitamin B12 deficiency

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In developing countries like India, nutritional deficiencies are prevalent and hyperpigmentation due to protein energy malnutrition, zinc deficiency and pellagra are common. Indian women, especially vegetarian are prone to vitamin B12 deficiency. Vitamin B12 deficiency can present as anaemia, neurological defect, gastrointestinal symptoms or dementia. Hyperpigmentation as the first presentation of Vitamin B12 deficiency is rare. Our patient, a 45 year-old Hindu vegetarian female presented to us with generalized hyperpigmentation. Examination revealed associated anaemia and peripheral neuropathy. Laboratory investigation confirmed vitamin B12 deficiency. Clinical features along with hyperpigmentation improved with vitamin B12 supplementation. We report this case to highlight this rare manifestation of vitamin B12 deficiency. A high index of clinical suspicion is warranted to diagnose the case. Since India is a country with a large number of potential vitamin B12 deficiency cases, the physicians need to be aware of all the varied manifestations of this vitamin deficiency. In case of hyperpigmentation, nutritional aspect must be ruled out as it is reversible. Early replacement therapy may also help to prevent morbidities like dementia and neuropathy.
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54 Journal of the association of physicians of india vol 62 published on 1st of every month 1st august, 2014
Generalised Hyperpigmentation in Vitamin B12
Deciency
Gouranga Santra
*
, Rudrajit Paul
**
, Sumit Kr Ghosh
**
, Debojyoti Chakraborty
***
,
Shubhabrata Das
***
, Sourav Pradhan
***
, Abhishek Das
***
Abstract
In developing countries like India, nutritional deficiencies are prevalent and hyperpigmentation due to
protein energy malnutrition, zinc deficiency and pellagra are common. Indian women, especially vegetarian
are prone to vitamin B12 deficiency. Vitamin B12 deficiency can present as anaemia, neurological defect,
gastrointestinal symptoms or dementia. Hyperpigmentation as the first presentation of Vitamin B12
deficiency is rare. Our patient, a 45 year-old Hindu vegetarian female presented to us with generalized
hyperpigmentation. Examination revealed associated anaemia and peripheral neuropathy. Laboratory
investigation confirmed vitamin B12 deficiency. Clinical features along with hyperpigmentation improved
with vitamin B12 supplementation. We report this case to highlight this rare manifestation of vitamin B12
deficiency. A high index of clinical suspicion is warranted to diagnose the case. Since India is a country
with a large number of potential vitamin B12 deficiency cases, the physicians need to be aware of all
the varied manifestations of this vitamin deficiency. In case of hyperpigmentation, nutritional aspect
must be ruled out as it is reversible. Early replacement therapy may also help to prevent morbidities like
dementia and neuropathy.
*
Associate Professor, Midnapore
Medical College, Midnapore;
**
Assistant Professor,
***
Post
Graduate Trainee, Dept. of
Medicine, Medical College, 88
College Street, Kolkata 700 073
Received: 17.09.2012;
Revised: 11.12.2012;
Accepted: 17.01.2013
Introduction
V
itamin B12 deficiency (VBD) is now recognised as a common public health problem
of India.
1
This can present as anaemia, neurological defect, gastrointestinal
symptoms or dementia.
Hyperpigmentation as the first presentation of VBD is only
rarely reported. We here present a case of VBD presenting with slow onset generalised
hyperpigmentation. As far as we could search, this is probably the first report of this
manifestation from Eastern India.
Case Report
A 45 year-old Hindu vegetarian female presented to us with generalised
hyperpigmentation for last two years. The hyperpigmentation was insidious in onset
and slowly progressive. At first, she noticed hyperpigmentation of the sun exposed
parts and scars. But later, it became generalised to involve whole of the skin surface,
including palms and soles (Figures 1 and 2). Hyperpigmentation was associated with
progressive generalised weakness and lassitude. On examination, we found severe
pallor and oral ulcers. There was no organomegaly. The ankle jerks were absent and
vibration sense was impaired up to ankles in both lower limbs. She had no history
of abdominal surgery, any other autoimmune diseases like vitiligo, or no history of
any drug intake.
Laboratory studies revealed haemoglobin 3.9 gm%, total leucocyte count 2300/
µL (neutrophil 28%; lymphocyte 68%; eosinophil 2%; monocyte 2%) and platelet
count of 94000/cmm. Red cell indices revealed MCV 118 µL, MCH 33.3 pg and
MCHC 30.8 g/dL. ESR was 75 mm / hour and there was slightly increased rouleaux
formation with a normochromic macrocytic blood picture in peripheral smear. Red
cell distribution width was 29.5%. Reticulocyte count was 2.7% with production
index of 0.351. Fasting sugar, urea and creatinine values were 78 mg%, 16 mg% and
0.9 mg% respectively. Blood electrolytes and liver function tests were also normal.
714 © Japi august 2014 vol. 62
Journal of the association of physicians of india vol 62 published on 1st of every month 1st august, 2014 55
Blood vitamin B12 level was 81.3 pg/ml (normal:
239-931 pg/ml by electrochemiluminiscence COBAS
e411) and folate level was 19 ng/ml (normal: 3-17 ng/
ml). Upper gastrointestinal endoscopy did not reveal
any atrophy of stomach mucosa. Anti-parietal cell
antibody was negative. Thyroid function test was
normal. Serum ferritin level was 452.1 ng/ml. Stool
examination did not reveal any worm infestation
and ultrasonography did not reveal any pancreatic
pathology. Urine porphyrin levels were negative.
Bone marrow aspiration and biopsy study revealed
megaloblastic cells with maturation defect (Figure 3).
Considering the severe pallor, two units of packed
red blood cell transfusion was given. Intramuscular
hydroxycobalamin (cyanocobalamin being not
available) was started. The subsequent haematological
pictures improved significantly (Table 1).
The patient did not need any more blood
transfusions. However, in the initial period of
vitamin replacement, she developed hypokalaemia
(serum K
-
= 2.6 mEq/L) which was corrected by oral
supplementation. She is being currently maintained
on regular monthly vitamin B12 injections. Her
neurological problems of lower limbs resolved and
hyperpigmentation improved after three months of
treatment (Figure 4).
Table 1 : Showing improvement of haematological pictures
after initiation of therapy
Before therapy 7 days 21 days 2 months
Haemoglobin (g%) 3.9 4.4 8 8.6
Reticulocyte count (%) 2.7 7.4 9.2 6
Total leucocyte count (/
cmm)
2300 2520 5400 5200
Platelet count (/cmm) 94000 100000 130000 145000
Fig. 1 : Shows hyperpigmentation of face and neck
Fig. 2 : Shows hyperpigmentation of left lower limb
Fig. 3 : Bonemarrow picture shows megaloblastic cells (red
arrows) with maturation defect
Fig. 4 : Shows improvement of hyperpigmentation after
vitamin B12 supplementation
© Japi august 2014 vol. 62 715
56 Journal of the association of physicians of india vol 62 published on 1st of every month 1st august, 2014
Discussion
Hyperpigmentation is caused by increase
of melanin, an increase in melanocytes, or the
deposition of another substance that adds colour
to the skin.
2
This may be caused by primary
dermatological disorders like melanoma or systemic
diseases like haemochromatosis. Protein energy
malnutrition, zinc deficiency and pellagra are
known to cause hyperpigmentation.
3
VBD is a rare
cause of hyperpigmentation. Thus, in developing
countries like India, hyperpigmented patients must be
investigated for nutritional deficiencies. The cause for
hyperpigmentation in VBD is thought to be an increase
in melanin synthesis with increased melanosomes in
basal layer of skin.
4
Few cases of hyperpigmentation
in VBD have been reported from India.
5-8
Indian women are prone to VBD; along with iron
and folate deficiencies.
9
This reflects the generally
poor nutritional status of Indian women. Other than
nutritional deficiency VBD may be caused by various
other causes like, tropical sprue and/or autoimmune
diseases. Often, the use of diluted cow’s milk during
weaning of infants may be a predisposing factor in
causing VBD and thus, paediatricians also need to
be aware of this entity.
8
VBD remains undiagnosed
in many cases.
VBD is associated with various muco-cutaneous
disorders like hyperpigmentation, vitiligo, hair
changes, glossitis and angular stomatitis.
5
Typically,
hyperpigmentation of dorsum of hands and feet with
oral mucosa is found.
5
One case reported from Varanasi,
India showed this type of hyperpigmentation as the
initial manifestation of VBD in a strictly vegetarian
male.
6
One case reported from Tamil Nadu, India
had non-pigmented polymorphic maculopapular
eruptions in upper trunk.
5
Sometimes, there may be
associated hyperpigmented nails and/or grey hair.
6,10
Associated pallor, macrocytosis and anti-parietal cell
antibodies, if present, can give clue to the underlying
cause of hyperpigmentation. All the pigmentary
changes are usually quickly reversible with adequate
vitamin B12 supplementation.
4-8,10
Our patient also
showed improvement of pigmentation with vitamin
B12 supplementation.
We report this case to highlight this rare
manifestation of VBD. Since India is a country with
a large number of potential VBD cases, the physicians
need to be aware of all the varied manifestations of
this vitamin deficiency. Besides pallor and glossitis,
atypical signs like hyperpigmentation may also be
the initial manifestation of VBD and a high index of
clinical suspicion is warranted. In any case of non-
resolving hyperpigmentation, the nutritional aspect
must be ruled out before investigating for the rare
aetiologies. Early replacement therapy may help to
prevent morbidities like dementia and neuropathy.
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716 © Japi august 2014 vol. 62
... Skin examination revealed multiple, diffuse, ecchymosed lesion scattered predominantly on the lower extremities [ Figure 1a-d]. His hemogram showed hemoglobin of 9.7 g/dL, leukocytes 6120/mm [3] (neutrophils 76.2%; lymphocytes 16%; monocytes 7.5%), platelets 169,000/mm [3] , mean corpuscular volume 87.8 fL, and mean corpuscular hemoglobin was 30.4 pg. The peripheral blood film (PBF) showed few normochromic macrocytoses, hypersegmented neutrophils, and thrombocytopenia. ...
... Skin examination revealed multiple, diffuse, ecchymosed lesion scattered predominantly on the lower extremities [ Figure 1a-d]. His hemogram showed hemoglobin of 9.7 g/dL, leukocytes 6120/mm [3] (neutrophils 76.2%; lymphocytes 16%; monocytes 7.5%), platelets 169,000/mm [3] , mean corpuscular volume 87.8 fL, and mean corpuscular hemoglobin was 30.4 pg. The peripheral blood film (PBF) showed few normochromic macrocytoses, hypersegmented neutrophils, and thrombocytopenia. ...
... These manifestations are reversible after the Vitamin B12 supplementation. [2,3] A hypothesis explained hyperpigmentation in Vitamin B12 deficiency due to increase synthesis of melanin with increased melanosomes in the basal layer of skin by decreasing the level of reduced glutathione, which activates tyrosinase and thus leads to transfer to melanosomes; a defect is also described in the melanin transfer between melanocytes and keratinocytes, resulting in pigmentary incontinence. [4,5] The patients with nutritional Vitamin B12 deficiency also had bleeding manifestations and qualitative abnormalities of platelets, i.e., abnormal aggregation to adenosine diphosphate, collagen, epinephrine, and ristocetin. ...
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A 40-year-old male presented because of generalized weakness, fatigability, and hyperpigmentation with ecchymosis, he was diagnosed to have dietary Vitamin B12 deficiency anemia. The hyperpigmentation and ecchymosis lesions resolved after Vitamin B12 supplementation. Beside hyperpigmented lesion on the skin, the presence of ecchymosis is a very rare manifestation of the disease. Thrombocytopenia in Vitamin B12 deficiency anemia rarely leads to ecchymosis.
... Along with available laboratory finding, rapid improvement after parenteral vitamin B12 strongly supported the diagnosis. 7 Cutaneous hyperpigmentation due to B12 deficiency was early described by Baker in 1963. 8 Later on, few reports were published in Indian subcontinent. ...
... Most of them were middle aged female with strict vegetarian diet. 7,9 Pigmentary changes are reversible and more common in darker-skinned patients. 9 Extremities are involved especially over the dorsum of the hands and feet, with accentuation over the interphalangeal joint, terminal phalanges (knuckle pad hyperpigmentation), intertriginous areas, oral mucosa and in recent scar. 10 Some patient also presented with generalized pigmentation. ...
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Hyperpigmentation as primary symptom is rare in vitamin B12 deficiency. This adolescent non vegetarian girl presented with hyperpigmentation, anaemia, glossitis and weight loss. She was worked up to find out the cause of anemia and hyperpigmentation. Addison disease was a strong provisional diagnosis. Her cortisol level was normal and megaloblastic anemia due to vitamin B12 deficiency was found. All of her symptoms were dramatically improved by injectable cobalamin. As vitamin B12 deficiency is a treatable condition so it should be ruled out in patient presenting with hyperpigmentation. Early replacement therapy also prevents multisystem involvement like bone marrow failure and demyelinating neurological disease. J Bangladesh Coll Phys Surg 2021; 39(1): 62-67
... Since then, there have been sporadic case reports with descriptions of the peculiar skin-hair-nail changes in patients with megaloblastic anemia. 9,6,13 In a recent study from southern India, hyperpigmentation has been observed to be an early and consistent feature of vitamin B12 deficiency. 6 Vegetarian diets can be classified as lacto-vegetarian, ovo-vegetarian, lacto-ovo-vegetarian, or vegan. ...
... And Santra G et al also showed dramatic improvement of skin hyperpigmentation with parenteral cobalamin therapy. 15,13 Thus, cases with knuckle pigmentation were associated with a greater degree of B12 deficiency; though this lacked statistical significance, but it has highlighted the importance of knuckle hyperpigmentation as a significant clinical marker in such patients. However, large-scale population-based studies are required to validate our findings. ...
... 3 Skin manifestations of vitamin B12 deficiency are hyperpigmentation, vitiligo, angular glossitis and scanty hypopigmented hairs which reverses after vitamin B12 treatment. 4,5 Similar case has been reported by Pahadiya HR et al. 6 Deficiency of vitamin B12 may cause bleeding and platelet qualitative defect which is alarming, but was not present in the case discussed here. 7 ...
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Vitamin B12 deficiency presents as megaloblastic anemia with neurological, skin and other clinical manifestations. We present here an interesting case of anemia presenting with generalized weakness and nonspecific symptoms in a female who is a vegetarian. There was acral hyperpigmentation without any other clinical features, Investigations revealed megaloblastic anemia with low vitamin B12 and normal RBC folate levels. The patient improved after blood transfusion and intramuscular vitamin B12 injections and the skin lesions faded away suggesting vitamin B12 deficiency to be the cause of hyperpigmentation, which is an uncommon manifestation. The importance lies in the fact that this cause of reversible hyperpigmentation should be thought of by clinicians to start prompt treatment.
... 3 Skin manifestations of vitamin B12 deficiency are hyperpigmentation, vitiligo, angular glossitis and scanty hypopigmented hairs which reverses after vitamin B12 treatment. 4,5 Similar case has been reported by Pahadiya HR et al. 6 Deficiency of vitamin B12 may cause bleeding and platelet qualitative defect which is alarming, but was not present in the case discussed here. 7 ...
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Reversible Hyperpigmentation due to Vitamin B12 deficiency
... Hyperpigmentation secondary to protein energy malnutrition, zinc deficiency, and niacin deficiency (pellagra) is primarily reported in low-income countries. 2 Mechanistically, melanocyte recruitment is often confined to the dorsum of the hands and feet, with interphalangeal joint involvement in patients with severe disease. 3 Our patient's atypical mucosal involvement mirrors prior cases attributable to dietary deficiencies. ...
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Reversible cutaneous hyperpigmentation often occurs in the setting of nutritional deficiencies and protein energy malnourishment, with atypical presentations arising from autoimmune disease. Here, we present a 52-year-old female with hypertension, type 1 diabetes, and Hashimoto’s thyroiditis, under the diagnosis of polyglandular autoimmune syndrome type II, referred for evaluation of asymptomatic hyperpigmentation of the palms, soles, hard palate, and tongue for 6 months. The patient underwent a significant work-up, including esophagogastroduodenoscopy, which revealed hypertrophic gastropathy as well as evidence of acquired B12 deficiency secondary to pernicious anemia. The patient was initiated on B12 supplementation, with eventual resolution of mucocutaneous findings.
... Like any disease, patients with VitB12 deficiency can present with atypical manifestations. Some reported findings include dysphagia, hyperpigmentation, psychosis, and acute dementia [30][31][32][33]. ...
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... Presentation with hyperpigmentation is unusual for patients with inborn errors of cobalamin metabolism, although there are rare reports of hyperpigmentation in general vitamin B 12 deficiency (e.g. (22)(23)(24)). Hyperpigmentation has not been noted in any of the 16 patients with LMBD1 deficiency (5,(16)(17)(18)(19), although some patients had skin rash or eczema. ...
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A case of reversible generalized hyperpigmentation of the skin and nails with reversible premature gray hair due to vitamin B12 deficiency is reported. The cause of the vitamin B12 deficiency in this patient was pernicious anemia. The pigmentation of his skin and hair returned to normal after treatment with intramuscular cyanocobalamin.
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The cause of hyperpigmentation usually is traced to the activity and presence of melanocytes. Café au lait macules may be solitary benign findings or may indicate the presence of neurofibromatosis with its associated complications. Diffuse hyperpigmentation should prompt a search for offending medications or systemic diseases such as hemochromatosis, hyperthyroidism, and Addison's disease. In these instances, the hyperpigmentation may be ameliorated by discontinuing offending medications, performing serial phlebotomy in patients with hemochromatosis, instituting cause-specific treatments in patients with hyperthyroidism, and replacing deficient glucocorticoids and mineralocorticoids in patients with Addison's disease. Cosmetic treatment with bleaching agents or lasers can be used to decrease pigmentation of ephelides (freckles) and lentigines.
Malnutrition -clinical presentation Medscape reference; WebMD. [Updated
  • Hr Shashidhar
Shashidhar HR. Malnutrition -clinical presentation. Medscape reference; WebMD. [Updated 2011 Oct 25; Cited 2012 Aug 20]. Available online from http://emedicine.medscape.com/ article/985140-clinical.