a clinical pandora: unusual manifestations of vitamin b12 deficiency

A middle-aged male presented with gradually progressive fatigue and dementia. He was anemic, jaundiced, had cardiomegaly, a multinodular goiter, diffuse muscle wasting, Lhermitte′s sign, and features of neuropathy. Patient was found to be Vitamin B12 deficient as a part of anemia evaluation with associated subclinical hyperthyroidism. Anti-thyroid peroxidase antibody was positive. Pernicious anemia as a part of polyglandular syndrome could not be proven as Schilling′s, and other tests were not available. Magnetic resonance imaging of the spinal cord was done to evaluate the muscle wasting which showed myelopathic changes. B12 correction was started which reversed jaundice and anemia. Echocardiogram showed dilated cardiomyopathy probably due to chronic anemia and subclinical hyperthyroidism. The patient was symptomatically better at discharge. On follow-up, the patient had markedly improved symptomatically as well as biochemically. The fact remains that a simple problem might be compounded by a multitude of findings while a major diagnosis and its management would solve a majority of problems faced by the patient.