doc_clotaire
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A 34 yo male who recently emigrated from Asia come to the clinic and complains of 2 months hystory of exertional shortness of breath and easy fatigability . He has been taking Isionazid and Rifampin for his tuberculosis which was diagnosed 4 months ago . Due to his religious belief , he completely turned into a vegeterian for the last year . Physical examination reveals pallor . Peripheral smear shows macrocytosis with hypersegmented polymorphonuclear neutrofil . His WBC and platelet count are within normal . This patient 's most likely problem is due to which of the following ?
a ) Vit B12 deficiency because of the vegeterian diet
b ) Vit B12 deficiency because of pernicious anemia
c ) Drug -induced B12 deficiency
d ) Myelodysplastic syndrome
e ) Chronic Myeloid Leukemia
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| sprint123
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hey doc..I am thinking of this sequence.
Macrocytosis with hypersegmented neutrophils--->So,should be wither B12 or Folate defciency
INH prone to cause B6 def and hence C ruled out
Between a and B,even though the most common cause of B12 deficiency is Pericnicious anaemia---H/o vegetarian diet cannot be rules out.
I go with A...Any suggestions?
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| Justice
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Most likely (A)
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| Justice
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sprint123 wrote:
Between a and B,even though the most common cause of B12 deficiency is Pericnicious anaemia---H/o vegetarian diet cannot be rules out.
I go with A...Any suggestions?
No history/clinical data suggestive of pernicious anemia...
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| sachida
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I will go with A
B: no correlative symptoms of pernicious anemia
C: Only drug used in tuberculosis that can cause B12 def picture is Streptomycin. INH does B6 deficiency. INH & Refampin induced chrnoic gastritis can result in to similar picture but no mention of chronic gastritis.
D: MDS & E: CML excluded due to normal counts
I thought it takes >1 year to develop B12 def on strict vegan diet but tuberculosis might have taken out his appetite and resulted in B12 def.
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| dr.wad
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A
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| Aashi
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b ) Vit B12 deficiency because of pernicious anemia
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| radonc
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Answer A.
Vit B12 is almost entirely derived from animal products. Although pernicious anaemia is the most common cause of Vit B12 def, it's unlikely here because it usually affects the older age group, typically those with fair skin, blue eyes and white hair.
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| star1
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A
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| NE
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Should be B
A- B 12 is stored in liver and is available for supply 6-9 years
C- B12 deficiency is not side effect of those 2 drugs
D, E- other TR and WBC are normal in number.
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| snake0613
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b
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| doc_clotaire
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The answer is B for the same reason that NE explains and pernicious anemia is the most common cause of B12 def
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| nany
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A
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| Justice
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To be honest, I would like to see more detailed explanation of why the correct answer is (B)... The guy does not have history of gastric surgery, or any other evidence of loss of intrinsic factor... I could understand if they say they the Pt has eosinophylia suggestive of diphyllobothrium, but...
I don't also think that endogenous supply of B12 can cover 6-9 years... Usually it's up to three years provided that man has enough meet products in his meal... I grew up in Asia and know that most of the time people eat lot's of herbs, veggies, rice and tandoori bread... All of this is quite plane for B12... And if this guy switched his diet to the strict vegetarian one, he could easy develop megaloblastic anemia, as per Q stem...
Any comments are welcome...
So, I stay firm with my (A)
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| Aashi
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Dear Justice---------->read the q once more, this guy is on a veg diet < 1yr it takes > 3 years for one to develop b12 def on a pure veg diet, so answer A is R/O, and the MCC of megaloblastic anemia is pernicious anemia, and someone explained above that probably his appetite was massively reduced due to his TB, this guy is on t/t for 4 months, he mite have got his appetite back and restored his lost B12 stores
and justice this is a UW q..no matter how much we disagree with the answer, the answer remains the same and its B...
GL
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| Justice
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So, in the absence of exogenous B12 (i.e. on a vegetarian diet) it takes >3 years to deplete endogenous B12 and develop megaloblastic anemia, but, in case of reduced, or even absent appetite it takes only 4 months? How can this be? Where are the losses of endogenous B12? Can anyone explain that???
I do trust UW Q bank, but sometimes its explanations are confusing...
Edited by Aashi on 04/17/07 - 12:59 PM
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| Aashi
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Justice, what i explained above is exactly how UW answered to this q.and if that doesnt make any 'sense' to u, dont get offended with me, coz that is UW explanation and to digest the concepts what UW has to offer is totally up2 u. and i agree with u ,this q is vague,and that is y only 9% ppl answred this q correctly in UW.
and if u still has a problem digesting the answer to this q, pls contact UW,and paste ur concern there, probably they can give u some positive feed back and give you an answer which can make some 'sense' to you..
GL
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| Justice
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Aashi wrote:
Justice, what i explained above is exactly how UW answered to this q..to digest the concepts what UW has to offer is totally up2 u. and i agree with u ,this q is vague,and that is y only 9% ppl answred this q correctly in UW.
and if u still has a problem digesting the answer to this q, pls contact UW,and paste ur concern there, probably they can give u some positive feed back and give you an answer which can make some 'sense' to you..
GL
Sure...
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| doc_clotaire
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Folks , This is exactly UW explanation , I decided to write it down to avoid unnecesarry confusion .
The most likely diagnosis is Vitamin B12 deficiency due to pernicious anemia , which is an autoinmune disease resulting from the destruction of parietal cell . The nest step in management of this patient is measurement of the intrinsic factor antibody titer and B12 levels
( Choice A ) A stric vegeterian diet can cause B12 deficiency , however the total body Vit B12 are depleted slowly and can usually last for 3 to 4 years after starting such a diet . This patient has been on a vegeterian diet for only one year , therefore , a diet related B12 deficiency is very unlikely .
Like Aashi said : this is UW question and only 9 % of people answered it correcly because it 's very vague and confusing . I post it here because I thought it could give us a valuable idea on how to deal with this king of questions as they come on the real exam . Folks , This is a UW question and answer . I understand that every body has their own opinion but it 's unfortunately irrelevant for board purpose . Whether or not you agree, it definitly does not change the answer .
Thank you very much and Happy studying  !
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| sachida
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I am bummed
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