Professional Documents
Culture Documents
Case Report
A Reversible Cause of Skin Hyperpigmentation and
Postural Hypotension
Rabia Cherqaoui,1 Mehreen Husain,1 Sujay Madduri,1
Pamela Okolie,2 Gail Nunlee-Bland,1 and James Williams1
1
2
1. Introduction
Vitamin B12 is a water soluble vitamin, present in various
forms: cyanocobalamin (vitamin B12 ), hydroxocobalamin
(vitamin B12a ), aquacobalamin (vitamin B12b ), nitritocobalamin (vitamin B12c ), 59-deoxyadenosylcobalamin (coenzyme B12 ), and methylcobalamin (methyl B12 ). Its deficiency
is a major health issue and a major diagnostic challenge; its
presentation varies from being asymptomatic to affecting
multiple organ systems. Some of the better studied and better
known manifestations are hematologic such as macrocytic
anemia, pancytopenia and neurological, such as orthostatic
hypotension, paraesthesias, and abnormal gait [1, 2]. Some of
the lesser known manifestations are cutaneous such as skin
hyperpigmentation, stomatitis, and hair and nail changes.
These may be important to recognize as early treatment may
prevent potentially irreversible complications.
2. Case Presentation
2.1. Case 1. A 40-year-old African American woman with
history of myasthenia gravis, Hashimotos thyroiditis stable
on thyroxine replacement, and childhood asthma was seen
Figure 1
Table 1: Summary of patients laboratory results.
Investigation
Hemoglobin (gm/dL)
Hematocrit %
Mean corpuscular volume: MCV (fL)
Serum vitamin B12 (pg/mL)
Thyroid-stimulating hormone: TSH (milli-int units/L)
Free thyroxine (microgm/dL)
Plasma morning cortisol (microgm/dL)
Post-adrenocorticotropic hormone (ACTH) plasma cortisol (microgm/dL)
Pretreatment
10.9
31.6
113
67
1.36
1.47
7.1
27.3
Posttreatment
10.8
31.1
86.4
412
Reference range
1216 gm/dL
43.3%46.6%
80100 fL
200950 pg/mL
0.44.0 mIU/L
0.72.0 mcg/dL
Normal > 18
Reference values are affected by multiple variables, including patient population and laboratory method used.
Figure 2
Figure 3
3. Discussion
Studies show a prevalence of cobalamin deficiency around
20% (ranging from 5 to 60% depending on parameters for
cobalamin) in industrialized nations [3]. The primary source
of vitamin B12 is derived from animal products such as
Investigation
Hemoglobin
Hematocrit
MCV
Platelet
Total white count
Peripheral smear
Serum vitamin B12
Serum folate
Patient value
(pretreatment)
Reference
range
10.5 gm/mL
1216 gm/dL
30.4
43.3%46.6%
121 fL
80100 fL
133 109 /L 177406 Th/cm
4.9 109 /L 3.210.6 109 /L
Macrocytosis
55 pg/mL
200950 pg/mL
10.24
41.11
Normal > 18
Historically, Thomas Addison described pernicious anemia and Addisons disease. There is a debate about whether
Thomas Addison himself mistakenly reported both clinical
entities in his 1855 monograph on adrenal disease [13]. Both
disease entities share several clinical features particularly
asthenia, gastrointestinal symptoms, hyperpigmentation, and
hypotension. Consequently, it may be worthwhile to consider
vitamin B12 deficiency and determine serum B12 level in
all the patients with symptoms suggestive of Addison disease such as hyperpigmentation and orthostatic hypotension. Early diagnosis can limit morbidity and inappropriate
workups. It is also important to remember that, although
uncommon, both diseases can coexist in the same patient in
the context of polyglandular autoimmune syndromes.
The dermatologic manifestations, first described in 1944
by Dr Bramwell Cook [14], are often overlooked. The cutaneous manifestations described in the literature include but
are not limited to skin hyperpigmentation, hyperpigmentation of surgical scars [15], and mucus membrane of the vulva
[16], vitiligo, recurrent angular stomatitis, and hair changes.
In a study of 63 patients by Aaron et al. glossitis (31%) was
the most common mucocutaneous presentation, followed by
skin hyperpigmentation (19%), hair changes (9%), angular
stomatitis (8%), and vitiligo (3%) [16]. Characteristically,
hyperpigmentation is observed in the oral mucosa and over
the dorsum of hands and feet, with accentuation over the
interphalangeal joints and terminal phalanges [17], occasionally in the creases of palms and soles, rarely on lower
extremities. The nails may have hyperpigmented streaks
with pale nail beds. The mechanism of hyperpigmentation
is unknown although increased melanin synthesis has been
suggested [18]. Premature graying of scalp hair has also been
described [19]. In primary adrenal insufficiency, hyperpigmentation of mucous membranes and skin, particularly of
body creases, pressure points, areolas, anogenital area, and
scars, is considered a cardinal manifestation of this disease.
The hyperpigmentation seen in Addison disease has been
linked to increased melanocyte-stimulating hormones (alpha
and beta MSH) and adrenocorticotrophin (ACTH).
4. Conclusion
Vitamin B12 deficiency may be more common than generally
thought and is most likely under-diagnosed due to varied and
unusual presentations. It may be worthwhile to consider vitamin B12 deficiency and determine serum B12 level in all the
patients with symptoms suggestive of Addison disease such
as hyperpigmentation and orthostatic hypotension. Early
diagnosis can limit morbidity and inappropriate workups.
Hyperpigmentation associated with vitamin B12 deficiency is
completely reversible with treatment.
Conflict of Interests
The authors declare no conflict of interests.
References
[1] S. P. Stabler, R. H. Allen, D. G. Savage, and J. Lindenbaum,
Clinical spectrum and diagnosis of cobalamin deficiency,
Blood, vol. 76, no. 5, pp. 871881, 1990.
[2] J. Lindenbaum, E. B. Healton, D. G. Savage et al., Neuropsychiatric disorders caused by cobalamin deficiency in the absence of
anemia or macrocytosis, The New England Journal of Medicine,
vol. 318, no. 26, pp. 17201728, 1988.
[3] E. Andr`es, N. H. Loukili, E. Noel et al., Vitamin B12 (cobalamin) deficiency in elderly patients, Canadian Medical Association Journal, vol. 171, no. 3, pp. 251259, 2004.
MEDIATORS
of
INFLAMMATION
The Scientific
World Journal
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Gastroenterology
Research and Practice
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Journal of
Diabetes Research
Volume 2014
Volume 2014
Volume 2014
International Journal of
Journal of
Endocrinology
Immunology Research
Hindawi Publishing Corporation
http://www.hindawi.com
Disease Markers
Volume 2014
Volume 2014
PPAR Research
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Volume 2014
Journal of
Obesity
Journal of
Ophthalmology
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Evidence-Based
Complementary and
Alternative Medicine
Stem Cells
International
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Volume 2014
Journal of
Oncology
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Volume 2014
Parkinsons
Disease
Computational and
Mathematical Methods
in Medicine
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
AIDS
Behavioural
Neurology
Hindawi Publishing Corporation
http://www.hindawi.com
Volume 2014
Volume 2014
Volume 2014