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Previous Volume 338:995 April 2, 1998 Number 14 Next

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To the Editor: The article by Toh et al. (Nov. 13 issue) ¹ on pernicious anemia includes a discussion of the neurologic complications of this disorder. The authors ignore a major point, which is that the neurologic manifestations of vitamin B₁₂ deficiency can occur in a patient with a normal hematocrit and normal red-cell indexes. This lack of parallelism between megaloblastic anemia and neurologic signs is an obstacle to the early diagnosis of neurologic disease due to vitamin B₁₂ deficiency. This concept is supported by a series of 141 patients with neuropsychiatric disorders caused by cobalamin deficiency, of whom 40 (28 percent) had no anemia or macrocytosis.²

Oren Zimhony, M.D.
Albert Einstein College of Medicine
Bronx, NY 10461

References

1. Toh B-H, Van Driel IR, Gleeson PA. Pernicious anemia. N Engl J Med 1997;337:1441-1448. [Free Full Text]
2. Lindenbaum J, Healton EB, Savage DG, et al. Neuropsychiatric disorders caused by cobalamin deficiency in the absence of anemia or macrocytosis. N Engl J Med 1988;318:1720-1728. [Abstract]

To the Editor: Dr. Zimhony has raised the important point that neurologic manifestations of vitamin B₁₂ deficiency may occur in the absence of anemia or megaloblastosis. Despite the introduction of new tests for vitamin B₁₂ deficiency, measurement of serum vitamin B₁₂ remains the mainstay of diagnosis,¹ and this assay should be requested for patients with neuropsychiatric disorders of unknown cause.

We wish to point out an error in our article. On page 1441, in the fifth line, second paragraph of the left column, the words "cooked liver" should have been "raw liver."

Ban-Hock Toh, M.B., B.S., D.Sc.
Ian R. van Driel, Ph.D.
Paul A. Gleeson, Ph.D.
Monash Medical School
Prahran, Victoria 3181, Australia

References

1. Chanarin I, Metz J. Diagnosis of cobalamin deficiency: the old and the new. Br J Haematol 1997;97:695-700. [CrossRef][Medline]

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