Central Nervous System Complication due to Pernicious Anemia in a Patient with Rheumatoid Arthritis

Jae Myung Lee; Jee Won Chai; Kichul Shin

doi:10.4078/jrd.2015.22.5.327

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Lee, Chai, and Shin: Central Nervous System Complication due to Pernicious Anemia in a Patient with Rheumatoid Arthritis

Case Report

J Rheum Dis 2015;22(5):327-331.

Published online: 31 October 2015

DOI: https://doi.org/10.4078/jrd.2015.22.5.327

Central Nervous System Complication due to Pernicious Anemia in a Patient with Rheumatoid Arthritis

Jae Myung Lee¹, Jee Won Chai², Kichul Shin¹

¹Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea

²Department of Radiology, Seoul National University College of Medicine, Seoul, Korea

Corresponding to: Kichul Shin, Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea. E-mail: kideb1@gmail.com

Received 15 September 2014 Revised 15 December 2014 Accepted 16 December 2014

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Pernicious anemia (PA) is an autoimmune disease characterized by atrophic gastritis and deficiency in intrinsic factor leading to impairment of vitamin B12 absorption in the ileum. Anemia is commonly found in rheumatoid arthritis (RA); however, PA is rarely found in RA. There are few reports describing patients with both conditions; none in Korea to date. We report on a case of a 46-year-old female who presented with hypesthesia and general weakness. She was previously diagnosed as seropositive RA with myelodysplastic syndrome. She had severely impaired sensation, especially for vibration and proprioception in all limbs. Subacute combined degeneration was observed on her magnetic resonance imaging and serum vitamin B12 level was very low. Further exam results were consistent with PA and her symptoms improved with cobalamin injection. This case demonstrates that PA should be considered in RA patients presenting with both central nervous system manifestations and anemia.

Keywords: Pernicious anemia, Rheumatoid arthritis, Vitamin B12

REFERENCES

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Figure 1.

Posterior tibial nerve somatosensory evoked potential of the patient showed normal absolute latencies in both TN1, LN1, but P1 wave was absent on both sides, which indicates central conduction defect of the thoracic spinal cord. Median nerve somatosensory evoked potentials were normal, which demonstrates normal sensory pathways above the cervical spinal cord. ASIS: anterior superior iliac spine.

Figure 2.

Magnetic resonance imaging study of the spinal cord showing demyelination involving dorsal columns of the spinal cord from T9 to L1 shown as a linear high intensity signal (arrows) on the T2-weighted image.

Figure 3.

Atrophic mucosal changes in gastric antrum and body.

Table 1.

Summary of pernicious anemia cases in RA

Author [Reference]	Year	No. of RA	No. of RA with PA	Summary
Partridge and Duthie [8]	1963	2,544	27	Megaloblastic anemia in 35 cases (1.38%) of 2,544 RA patients, as opposed to 15 cases (0.27%) of 5,515 controls. Of the 35 RA patients with megaloblastic anemia, 27 were thought to have PA (1.05%).
Bieder and Wigley [9]	1964	20	2	One patient among 20 RA patients had longstanding RA associated with classical PA and another RA patient with PA associated with subacute combined degeneration which symptom improved following intensive vitamin B12 therapy.
Carter et al. [10]	1968	92	1	One 71-year-old female patient diagnosed as PA among 92 RA patients.
Pitcher et al. [11]	1970	100	3	Of 100 patients with RA, impaired absorption of vitamin B12 was found in 3 cases.
Ghazi [12]	1972	151	5	Of 99 patients with PA, RF positivity was significantly higher in PA than in controls (11/99 vs. 7/182). There was no correlation between RF and circulating antibody to IF in PA. IF antibody was not detected in any of 151 rheumatoid sera.
Abraham et al. [13]	1993	1	1	A patient with a 46-year history of vitiligo who also had RA and PA.
Wang et al. [14]	2001	1	1	A 62-year-old female patient diagnosed as PA followed by RA 6 years later.

IF: intrinsic factor, PA: pernicious anemia, RA: rheumatoid arthritis, RF: rheumatoid factor.

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