Psychiatric manifestations are frequently associated with
pernicious anemia including depression,
mania,
psychosis,
dementia. We report a case of a patient with
vitamin B12 deficiency, who has presented severe depression with delusion and
Capgras' syndrome, delusion with lability of mood and
hypomania successively, during a period of two Months. Case report -
Mme V., a 64-Year-old woman, was admitted to the hospital because of
confusion. She had no history of psychiatric problems. She had history of diabetes,
hypertension and femoral
prosthesis. The red blood count revealed a normocytosis with
anemia (
hemoglobin=11,4 g/dl). At admission she was uncooperative, disoriented in time and presented memory and attention impairment and
sleep disorders. She seemed sad and older than her real age. Facial expression and spontaneous movements were reduced, her speech and movements were very slow. She had depressed mood, guilt complex, incurability and devaluation impressions. She had a
Capgras' syndrome and delusion of persecution. Her neurologic examination, cerebral scanner and EEG were postponed because of uncooperation. Further investigations confirmed
anemia (
hemoglobin=11,4 g/dl) and revealed
vitamin B12 deficiency (52 pmol/l) and normal
folate level.
Antibodies to parietal cells were positive in the serum and
antibodies to
intrinsic factor were negative. An
iron deficiency was associated (serum
iron=7 micromol/l; serum
ferritin concentration=24 mg/l; serum
transferrin concentration=3,16 g/l). This association explained normocytocis
anemia. Thyroid function, hepatic and renal tests, glycemia, TP, TCA, VS, VDRL-TPHA were normal.
Vitamin B12 replacement
therapy was started with
hydroxycobalamin 1 000 ng/day im for 10 days and
iron replacement
therapy. Her mental state improved dramatically within a few days. After one week of treatment the only remaining symptoms were lability of mood, delusion of persecution,
Capgras' syndrome but disappeared totally 9 days after the beginning of the treatment. A neurologic examination was possible because of cooperation. All the tendon reflexes of inferior members were absent. The plantars were in flexion and there was a left inferior member
hypoesthesia. The cerebral scan and EEG were normal. Fundic biopsy, realized by fibroscopy, revealed fundic atrophia and intestinal
metaplasia compatible with Biermers' disease. The
iron deficiency exploration concluded diet deficiency.
Mme V. appeared euphoric, her speech was very rapid with play on words and overactivity. This
hypomania state totally disappeared 3 days after. Six Months after her hospitalisation, she presented an
hypothyroidism (TSH=3,780; T3=1,35; T4=1,08). A
thyroid hormones replacement was started and she continued to receive Monthly B12 replacement. Discussion - This case report illustrates psychiatric manifestations of Biermers' disease. The clinical arguments in favour are: white woman, more than 60 Years old, no history of psychiatric problems, atypical symptoms (
confusional state with psychiatric symptoms), fluctuation of symptoms (severe depression with
confusional state, delusion of persecution and
Capgras' syndrome; delusion with lability of mood and
hypomania), dramatic improvement after 9 days of
vitamin B12 replacement
therapy. The
biological arguments are:
anemia,
vitamin B12 deficiency, normal
folate level, atrophia and fundic
metaplasia, positive
antibodies to parietal cells in the serum, association between Biermers' disease and
autoimmune disease (Haschimoto thyroidite). Psychiatric manifestations can occur in the presence of low serum B12 levels but in the absence of the other well recognized neurological and haematological abnormalities of
pernicious anemia. Mental or psychological changes may precede haematological signs by Months or Years. They can be the initial symptoms or the only ones. Verbank et al. described the case of a patient with
vitamin B12 deficiency in whom
hypomania,
paranoia and depression had been successively presented during a period of 5 Years before
anemia have been developed. The case of
Mme V. is similar in the succession of severe depression with delusion of persecution and
Capgras' syndrome, delusion with lability of mood and
hypomania, during a period of two Months. This report seems to be the first one of a sequence of several psychiatric states with
pernicious anemia during a period of two Months with normocytosis
anemia. To illustrate this illness we reviewed the literature regarding psychopathology associated with B12 deficiency. The most common psychiatric symptoms were depression,
mania, psychotic
symptoms, cognitive impairment and
obsessive compulsive disorder. The neuropsychiatric severity by
vitamin B12 deficiency and the therapeutic efficacy depends on the duration of signs and symptoms. Conclusion - We recommend consideration of B12 deficiency and serum B12 determinations in all the patients with
organic mental disorders, atypical psychiatric symptoms and fluctuation of symptomatology. B12 levels should be evaluated with
treatment resistant depressive disorders,
dementia,
psychosis or risk factors for
malnutrition such as
alcoholism or advancing age associated with neurological symptoms,
anemia, malabsorption, gastrointestinal surgery, parasite infestation or strict
vegetarian diet. In first intention, B12 deficiency should be researched by serum B12 determination (normal 200-950 pg/ml). Studies of
methylmalonic acid and
homocysteine showed that they are very sensitive functional indicators of
cobalamin status especially when other evidence of
cobalamin (B12) deficiency was equivocal. Measurement of
methylmalonic acid (normal 73-271 nmol/l) and
homocysteine (normal 5,4-13,9 micromol/l) should not replace the measurement of serum
cobalamin.