More Case histories from my family medical practice
Vitamin B12 blood levels aren't very useful on their own.
At age 80, Benny had very healthy readings for vitamin B 12 and homocysteine, 464 and 7.4 respectively.
5 years later the figures were 544 and 9.0.
2 more years on the homocysteine was up to 10.7 and I prescribed folic acid 500mcg daily as the vitamin B 12 level had been so good.
Another year on, now aged 88 his figures were 393 and a distinctly unhealthy 13.3. Despite the good blood level, I gave him vitamin B 12 injections. My notes then read “feels a bit better – unable to say in what way” and his homocysteine dropped in 7 weeks to 6.9, right back where it should be.
Nowadays my pathology providers automatically add a holotranscobalamin1
if the total B 12 is under 300, but the above result wouldn't have triggered it and my experience suggests that it doesn't help anyway. The suck it and see approach works better.
Eyeball versus microscope
This person had the right symptoms and signs on examination - persistent nausea and epigastric tenderness. They also had a progressively increasing size of their red blood cells from 87 to 92 over eight years. At the eight year mark the vitamin B 12 level was a rather low 219 and homocysteine a rather high 11.1 .
A couple of vitamin B 12 injections
later and “maybe a little more energy, not quite so languid.” The homocysteine dropped to
9.5 (14.4% drop.)
The day to day variation in homocysteine is up to 7.5% and the pathology test error can be 5%. If by an extremely unlikely set of circumstances, on the day of the first test both the person's body and the pathologist's equipment were at the top of their respective ranges, AND at the time of the second test both were at the bottom extreme, one could get 12.5% difference just by chance.
This person had topped that, and so the gastric biopsy was clearly not representative.
Husband not entirely to blame
(my observation) - "Very hesitant re speaking."
(my notes) - "H gets indignant with her if she doesn't watch the 6 pm news."
(in a letter from a specialist) - "Her major problem would seem to be her anxiety and social stresses. Her hesitancy was such that it was difficult to obtain a history from her."
She was wobbly on her feet, had poor sleep at times and her vitamin B12 level was low (130 pmol/L.)
Further notes read...
20th Aug - B12 injection
21st Aug - B12 injection
22nd Aug - Feeling much better!
29th Aug - More relaxed, less tense - physically (was having tightness across shoulders at back - which has eased markedly.) Not so stressed, trying to do too much - taking things a little more quietly.
Links to other case histories
First Case Histories page
and Second Case Histories page
and More cases page
to main index page of this site.
References - this case histories page
1. Holotranscobalamin, a marker of vitamin B-12 status: analytical aspects and clinical utility.