Etiology and clinical manifestations of vitamin B12 and folate deficiency http://www.uptodate.com.libproxy.ucl.ac.uk/contents/etiology-and-clinic...

Official reprint from UpToDate®

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Etiology and clinical manifestations of vitamin B12 and folate deficiency

Author Section Editor Deputy Editor

Stanley L Schrier, MD William C Mentzer, MD Jennifer S Tirnauer, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2014. | This topic last updated: Oct 08, 2014.

INTRODUCTION — Nutritional megaloblastic anemias were characterized over one hundred years ago. This term
identifies patients with anemia and macroovalocytic red cells (ie, mean corpuscular volume greater than 100 fL). The
bone marrow shows intense erythroid hyperplasia with abnormal (megaloblastic) morphology. The megaloblast, the
morphologic hallmark of the syndrome, is a product of impaired DNA formation, which in turn is due to deficiencies of
vitamin B12 (cobalamin, Cbl) or folate [1,2].

This topic will review the major causes and clinical manifestations of Cbl and folate deficiency. In this review, the
terms B12, Cbl, and cobalamin will be used interchangeably. The terms "folate" and "folic acid" are sometimes used
interchangeably; however, the vitamin is found in nature as a folate while folic acid (FA) is the synthetic, therapeutic
form.

The physiology of these vitamins, how lack of availability leads to a megaloblastic anemia with ineffective
erythropoiesis, and the diagnosis and treatment of these disorders are discussed separately. (See "Physiology of
vitamin B12 and folate deficiency" and "Diagnosis and treatment of vitamin B12 and folate deficiency".)

Deficiencies of Cbl and FA may also be present in the elderly and in those with alcohol abuse. These are discussed
separately. (See "Anemia in the older adult", section on 'Search for treatable disorders' and "Alcohol abuse and
hematologic disorders".)

VITAMIN B12 DEFICIENCY

Dietary intake and absorption — Animal products (meat and dairy products) provide the only dietary source of Cbl
for humans. The usual Western diet contains 5 to 7 mcg of cobalamin per day, while the minimum daily requirement
is listed as 6 to 9 mcg per day [3]. Total body stores of Cbl are 2 to 5 milligrams (2000 to 5000 mcg), approximately
one-half of which are in the liver. As a result, it takes years to develop vitamin B12 deficiency after absorption of
dietary B12 ceases [3].

Dietary Cbl in the presence of acid and pepsin in the stomach is liberated from its binding to protein and then quickly
binds to R factors (R binders, R proteins) in saliva and gastric juice. Cobalamin bound to R factors is not absorbed;
however, in the alkaline pancreatic enzyme milieu of the duodenum, cobalamin is freed from R proteins by
pancreatic proteases and then binds specifically and rapidly to gastric-derived intrinsic factor (IF). IF is a 45 kDa
glycoprotein with very high affinity for Cbl. The IF-Cbl complex binds to specific ileal receptors from which it is
absorbed in an energy requiring process that is still incompletely understood.

Thus, adequate absorption of cobalamin from the diet depends upon five factors [1-4]. (See "Physiology of vitamin
B12 and folate deficiency".)

● Dietary intake
● Acid-pepsin in the stomach to liberate Cbl from binding to proteins
● Pancreatic proteases to free Cbl from binding to R factors
● Secretion of intrinsic factor (IF) by the gastric parietal cells to bind to Cbl
● An intact ileum with functional Cbl-IF receptors

Once taken up by the ileal enterocytes, the Cbl that enters plasma bound to transcobalamin II binds to specific cell
surface receptors from which it enters cells by receptor-mediated endocytosis. Cbl in the cells is metabolized into

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two coenzymes: adenosyl-Cbl; and methyl-Cbl (figure 1) [4].

● Adenosyl-CBL is a cofactor, along with methylmalonyl-CoA mutase, converting methylmalonyl-CoA to

succinyl-CoA.
● Methyl-CBL is a cofactor, along with methionine synthase, converting homocysteine to methionine.

Causes of vitamin B12 deficiency — Vitamin B12 deficiency is usually due to inadequate absorption associated
with pernicious anemia (PA) or secondary to gastric disease (table 1). In contrast, folate deficiency is generally
attributable to an inadequate diet and/or alcoholism. The two deficiencies can coexist in some patients with
malabsorption, especially in those with tropical sprue.

Pernicious anemia — Pernicious anemia (PA; B12 deficiency caused by lack of intrinsic factor) is a common
cause of Cbl deficiency. It is usually under-diagnosed, and is not an uncommon problem in older adult subjects. One
series, for example, evaluated 729 subjects who were randomly solicited from the community [5]. The incidence of
PA was 4.1 percent in white and black women and 2.1 percent in white and black men; there were no cases in Latin
American or Asian American subjects. (See "Diagnosis and treatment of vitamin B12 and folate deficiency", section
on 'Diagnosing pernicious anemia'.)

The underlying pathogenesis of PA is thought to be autoimmune and may be part of a more general autoimmune
disorder called polyglandular autoimmune syndrome type 2 (PAS 2), which can include such disorders as
autoimmune thyroid disease, Addison's disease, type 1 diabetes mellitus, and vitiligo.

PA is associated with the following major conditions:

● Autoimmune metaplastic atrophic gastritis – A major component of PA is chronic atrophic gastritis, which is
associated with autoantibodies directed against gastric parietal cells in approximately 90 percent of patients
with PA. These antibodies are directed against hydrogen-potassium adenosine triphosphatase (H-K-ATPase),
which secretes hydrogen ions into the lumen in exchange for potassium [6,7]. Molecular mimicry between
Helicobacter pylori antigens and the H-K-ATPase has been invoked as a mechanism for this attack [8]. Parietal
cell injury appears to be directed by dendritic cells in the stomach that clear apoptotic parietal cells produced
during the normal turnover of gastric mucosa [9,10]. These dendritic cells travel to paragastric lymph nodes,
where they activate pathogenic CD4+ T cells that react with H-K-ATPase. (See "Metaplastic (chronic) atrophic
gastritis", section on 'Autoimmune metaplastic atrophic gastritis'.)

● Autoantibody formation against intrinsic factor – Cbl deficiency in PA is thought to result directly from an
autoimmune attack on gastric intrinsic factor (IF) [1,6]. Anti-intrinsic factor antibodies are detectable in the
serum in 50 to 70 percent of patients with PA, providing a highly specific (>95 percent) but relatively insensitive
(50 to 84 percent) test [1,11]. There are two types of anti-IF antibodies: one that blocks the attachment of Cbl to
IF; and one that blocks attachment of the Cbl-IF complex to ileal receptors [12]. The net result of these anti-IF
antibodies is to prevent absorption of dietary Cbl, leading to Cbl deficiency and its various sequelae. (See
"Diagnosis and treatment of vitamin B12 and folate deficiency", section on 'Antibodies to IF'.)

● Risk of gastric tumors – The chronic atrophic gastritis in PA is associated with an increased risk of
intestinal-type gastric cancer and of gastric carcinoid tumors. The latter are presumably due to prolonged
achlorhydria resulting from parietal cell loss, compensatory hypergastrinemia, and argyrophilic cell hyperplasia.
(See "Risk factors for gastric cancer", section on 'Pernicious anemia'.)

Gastrectomy and gastritis — Gastrectomy and gastritis are other gastric abnormalities that can produce Cbl
deficiency [1,13]. The absence of gastric acid and pepsin in these disorders results in impaired liberation of Cbl from
its binding to food proteins, while the absence of intrinsic factor prevents the normal absorption of food Cbl.

Risk factors for postgastrectomy Cbl deficiency and the time course of its development were studied in a
retrospective review of 469 and 176 patients with gastric cancer who had undergone either distal subtotal (DG) or
total gastrectomy (TG), respectively. Results included the following [14]:

● Cumulative rates of Cbl deficiency at four years post-gastrectomy were 100 and 16 percent for TG and DG,

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respectively.

● The median time to Cbl deficiency was 15 months after TG, whereas the median time was not reached after
DG. There was a positive linear correction between preoperative Cbl levels and the time to deficiency after
either TG or DG.

● The preoperative Cbl level was the only risk factor for Cbl deficiency after TG, whereas both preoperative Cbl
level and increased age were risk factors after DG.

The authors concluded that preoperative measurement and regular postoperative monitoring of Cbl levels are
necessary for the early detection and treatment of postgastrectomy Cbl deficiency.

Helicobacter pylori infection — A study from Turkey has suggested a link between infection with Helicobacter
pylori (HP) and low serum B12 levels [15]. Of 138 cobalamin-deficient patients, infection with HP was documented
by endoscopy in 77. In all 31 patients in whom the infection was successfully eradicated, the hematocrit, MCV, LDH,
and serum B12 levels returned to normal without the addition of vitamin B12 replacement therapy.

A potential link between susceptibility to infection with HP, atrophic gastritis, and low serum B12 levels has been
suggested, secondary to a common variation in the FUT2 secretor gene, whose product is a mediator of HP
attachment to human gastric mucosa [16-18]. (See "Pathophysiology of and immune response to Helicobacter pylori
infection", section on 'Bacterial attachment'.)

Older adults — Mild and usually subclinical cobalamin deficiency appears to occur (or be recognized) with
increased frequency (10 to 24 percent) in older adults [19-23].

● In a population-based cross-sectional analysis of 3511 older adults from the UK, the age-specific prevalence of
cobalamin deficiency was approximately 5 and 10 percent in those ages 65 to 74 and those ≥75 years of age,
respectively [23]. The prevalence of folate deficiency in this population was similar, although combined
cobalamin and folate deficiency was uncommon.

● In a series of 107 healthy, free living Dutch subjects between the ages of 74 and 80, 24 percent had evidence
of mild cobalamin deficiency [20]. Inadequate cobalamin intake or severe atrophic gastritis was present in less
than 30 percent of the study population, indicating that other mechanisms must contribute to the Cbl deficiency.

In contrast, food cobalamin malabsorption was a more important factor in a report from France of older adult patients
with proven cobalamin deficiency [24,25]. Food cobalamin malabsorption, caused primarily by gastric atrophy,
accounted for 60 to 70 percent of cases, while pernicious anemia accounted for 15 to 20 percent.

Food cobalamin malabsorption is primarily the result of an inability to release cobalamin from dietary proteins,
especially in the presence of reduced gastric acid secretion. It has been defined as cobalamin deficiency in the
presence of sufficient food cobalamin intake, a normal Schilling test using crystalline cobalamin, and an abnormal
Schilling test using protein-bound cobalamin. (See "Diagnosis and treatment of vitamin B12 and folate deficiency",
section on 'Schilling test'.)

Factors that may contribute to food cobalamin malabsorption in older adults include [25,26]:

● Gastric atrophy, achlorhydria

● Helicobacter pylori infection
● Intestinal bacterial overgrowth secondary to antibiotic treatment
● Long-term ingestion of biguanides, antacids, H2 receptor antagonists, and proton pump inhibitors
● Chronic alcoholism
● Gastric surgery/reconstruction for obesity (bariatric surgery) [27-29]
● Pancreatic exocrine failure
● Sjogren's syndrome

An important clinical issue to remember is that cobalamin deficiency is common in those over 65, although the

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anemia of cobalamin deficiency is very uncommon, particularly in patients in whom the anemia is not distinctly
macrocytic with no increase in hypersegmented neutrophils.

Intestinal disorders — A number of intestinal disorders can also cause Cbl deficiency. These include severe
pancreatic disease and small bowel diseases such as malabsorption, ileal disease (eg, including tuberculous ileitis,
lymphoma, amyloid, long-term survivors of pelvic irradiation), extensive resection or bypass, and Crohn's disease.
When jejunal blind loops are present, bacterial overgrowth within the loops competes for Cbl, leading to Cbl
deficiency [30]. (See "Gastrointestinal toxicity of radiation therapy" and "Management of the short bowel syndrome in
adults", section on 'Limited ileal resection' and "Management of the short bowel syndrome in adults", section on
'Extensive small bowel resection' and "Radiation therapy techniques in cancer treatment", section on 'Radiation
side-effects'.)

Fish tapeworm infestation — Although not as common currently, infestation with the fish tapeworm,
Diphyllobothrium latum, was once a classic cause of Cbl deficiency. It is still a common cause of Cbl deficiency in
those areas of the world in which there is consumption of raw fish. (See "Intestinal tapeworms", section on
'Diphyllobothriasis'.)

Medications — Prolonged use of proton pump inhibitors (eg, omeprazole) and histamine 2 receptor antagonists
(eg, cimetidine) can result in Cbl deficiency as a consequence of impaired release of Cbl from food in the absence of
gastric acid secretion (figure 2) [31-33]. (See "Pharmacology of antiulcer medications", section on 'Immune and
hematopoietic effects'.)

Approximately 10 to 30 percent of patients receiving metformin have diminished B12 absorption due to calcium-
dependent ileal membrane antagonism, an effect that can be reversed with supplemental calcium. (See "Diagnosis
and treatment of vitamin B12 and folate deficiency", section on 'Schilling test' and "Metformin in the treatment of
adults with type 2 diabetes mellitus" and "Overview and comparison of the proton pump inhibitors for the treatment
of acid-related disorders", section on 'Vitamin B12 malabsorption'.)

Inadequate dietary intake — In addition to gastrointestinal disease, cobalamin deficiency can result from
inadequate dietary intake in certain settings. Strict vegans, for example, avoid all animal products, and are at risk of
developing nutritional Cbl deficiency. In addition, women who are only moderate vegetarians, including those on a
“Mediterranean diet” which has little in the way of animal-source foods, may become Cbl deficient during pregnancy
and lactation; their infants may also be Cbl deficient [34,35]. The Cbl levels in cord blood are twice as high as
maternal blood levels, and Cbl needs are increased during lactation [34]. Thus, pregnant women who limit animal
protein intake may need Cbl assessment and supplementation. (See "Healthy diet in adults", section on
'Mediterranean diet' and "Vitamin supplementation in disease prevention", section on 'Special diets' and "Vegetarian
diets for children", section on 'Vitamin B12'.)

HIV infection — The prevalence of low serum levels of Cbl in patients infected with HIV has ranged from 10 to
39 percent [36]. Multiple causes have been suggested, including poor nutritional status, diarrhea, ileal dysfunction,
and exudative enteropathy. A long-term study has indicated that a serum level of vitamin B12 <125 pmol/L was an
independent predictor of poor survival and disease progression in HIV+ subjects [37]. (See "Hematologic
manifestations of HIV infection: Anemia", section on 'Nutritional deficiencies'.)

Nitrous oxide exposure — Nitrous oxide (N2O) inactivates cobalamin and its use in anesthesia or inhalant
abuse may precipitate RAPID hematologic and neuropsychiatric deterioration in Cbl-deficient subjects. (See
"Diagnosis and treatment of vitamin B12 and folate deficiency", section on 'Nitrous oxide exposure' and "Inhalant
abuse in children and adolescents", section on 'Nitrous oxide'.)

Hereditary causes — In rare cases, cobalamin deficiency is a hereditary disorder. Examples include production
of a qualitatively abnormal intrinsic factor [38,39], or decreased uptake of the intrinsic factor-cobalamin complex. The
latter condition, called Imerslund-Gräsbeck syndrome or juvenile megaloblastic anemia, appears to be due to a
mutation either in the gene for cubilin [40,41] or "amnionless" (AMN) [42]. It has been postulated that the
cubilin/AMN complex is the functional receptor essential for ileal cobalamin uptake as well as renal protein

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reabsorption (see below) [43,44]. (See "Physiology of vitamin B12 and folate deficiency".)

Patients with Imerslund-Gräsbeck syndrome also have varying degrees of proteinuria that is resistant to cobalamin
supplementation. Cubilin is heavily expressed in the renal proximal tubule and appears to mediate the reabsorption
of filtered albumin; thus, diminished reabsorption due to defective cubilin is presumably responsible for the
proteinuria in this disorder [45]. Cubilin also facilitates the reabsorption of the calcidiol (25-hydroxyvitamin D)-vitamin
D binding protein complex; patients with Imerslund-Gräsbeck syndrome have increased urinary losses of calcidiol
and the binding protein [46]. (See "Overview of vitamin D", section on 'Metabolism'.)

Other rare causes of cobalamin deficiency include congenital deficiency of transcobalamin, homocystinuria, severe
methylenetetrahydrofolate reductase deficiency, several abnormalities of methionine synthesis, abnormal lysosomal
membrane exporters for cobalamin, and abnormal cellular trafficking of cobalamin [47-54]. Several of these may
occur without a low vitamin B12 level and/or with a normal mean corpuscular volume (MCV).

Clinical manifestations

General considerations — Deficiency of both cobalamin and folate produce megaloblastic anemia, but only B12
deficiency produces neurologic changes. Another important difference between the two deficiencies is the time
required for a deficiency to develop. Because Cbl stores are so large in relation to daily intake, years of inadequate
Cbl intake or absorption are required before the onset of symptoms. On the other hand, symptoms of folate
deficiency can occur within four to five months after intake is diminished, since body stores are smaller (5 to 10 mg)
in relation to daily requirements (200 to 400 mcg).

Pernicious anemia is most common in Caucasians of northern European ancestry, and occurs as commonly in
blacks as in other Caucasian non-northern European groups. It usually affects older patients, possibly because of
the superimposition of age-related chronic atrophic gastritis. However, PA can occur under the age of 30 and can be
associated with other autoimmune diseases, such as thyroid disease and vitiligo. (See "Vitiligo".)

The classic clinical picture of cobalamin deficiency due to PA was that of a prematurely gray person of Northern
European descent whose skin was lemon-colored (reflecting the simultaneous presence of both anemia and
jaundice), mentally sluggish, had a shiny tongue (atrophic glossitis), and a shuffling broad-based gait. Examination
revealed hematologic changes (eg, macrocytic anemia with oval macrocytes and increased neutrophil lobulation)
and neurologic abnormalities (eg, loss of vibration sense and a positive Romberg test) [55]. This classic picture of
PA is now seen less frequently. It has been replaced by more subtle presentations which including the following:

● Coincident iron deficiency or homozygous alpha thalassemia-2 (in African Americans) can mask the
macrocytosis. (See "Pathophysiology of alpha thalassemia".) Affected patients may not be anemic and the
peripheral blood smear may show only hypersegmented neutrophils [1,56]. Hypersegmentation is an alteration
of late granulopoiesis whereas anemia, when present, reflects the severe ineffective erythropoiesis or
intramedullary destruction of erythroid precursors within the bone marrow.

● The patient may have hard-to-characterize neuropsychiatric problems consisting of paresthesias, numbness,
weakness, loss of dexterity, impaired memory, and personality changes [3].

● Cbl deficiency is one of the treatable causes of dementia; screening for Cbl deficiency (and hypothyroidism) is
recommended for patients being evaluated for this condition. (See "Evaluation of cognitive impairment and
dementia", section on 'Summary and recommendations'.)

In one recent series, for example, the diagnosis of Cbl deficiency was made in patients of whom only 29 percent had
anemia, and 64 percent had a MCV greater than 100 [1]. Hypersegmented neutrophils seen on peripheral smear
continue to provide a good clue. Because Cbl is required for all rapidly growing cells, including enteric mucosal cells,
patients with Cbl deficiency may complain of glossitis, vaginal atrophy, and malabsorption [1,57].

Neurologic changes — Neurologic problems, when present, consist of the classic picture of subacute combined
degeneration of the dorsal (posterior) and lateral spinal columns [3,58]. This lesion, specific for Cbl deficiency, is due
to a defect in myelin formation of unknown mechanism. The neuropathy is symmetrical and affects the legs more

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than the arms. It begins with paresthesias and ataxia associated with loss of vibration and position sense, and can
progress to severe weakness, spasticity, clonus, paraplegia, and even fecal and urinary incontinence [3]. (See
"Disorders affecting the spinal cord", section on 'Subacute combined degeneration'.)

Other neurologic abnormalities that can be seen include cerebellar ataxia, axonal degeneration of peripheral nerves
and central nervous system symptoms including memory loss, irritability, dementia, and extrapyramidal signs
[3,59,60]. Patients may present with Lhermitte's syndrome, a shock-like sensation that radiates to the feet during
neck flexion and/or a positive Romberg test. Optic atrophy is a rare complication and may progress to visual failure
[61]. In addition, cobalamin deficiency may precipitate optic neuropathy in those with Leber’s hereditary optic
neuropathy [62].

Whether cognitive decline in older subjects is associated with subclinical vitamin B12 deficiency is an unanswered
question [63]. (See "Evaluation of cognitive impairment and dementia", section on 'Laboratory testing' and
"Prevention of dementia", section on 'Vitamins B6, B12, and folate'.)

Of clinical importance, not all patients with neurologic abnormalities secondary to Cbl deficiency are either anemic or
have macrocytic red cell indices. As an example, among 141 consecutive patients with neuropsychiatric
abnormalities due to cobalamin deficiency, the hematocrit was normal in 34, the mean red cell volume was normal in
25, and both tests were normal in 19 [64].

A neurologic syndrome similar to subacute combined degeneration can be seen in patients with copper deficiency,
and the two conditions (ie, combined Cbl plus copper deficiencies) may coexist. Thus, continued neurologic
deterioration in a patient with a history of Cbl deficiency-related myelopathy and normal Cbl levels while receiving
Cbl replacement therapy should be evaluated for copper deficiency [65,66]. (See "Copper deficiency
myeloneuropathy".)

Skeletal changes — Vitamin B12 deficiency appears to be associated with an increased risk of osteoporosis
[67,68], and hip and spine fractures [69,70], possibly due to suppression of osteoblast activity [71,72].

Even subtle degrees of B12 deficiency may be associated with bone loss [73], although this has not been shown in
all studies [74]. Supplementation with vitamin B12 and folate has been shown to reduce hip fractures in a group of
older adult Japanese patients with residual hemiplegia after an ischemic stroke. However, there is insufficient data to
recommend this therapeutic approach in other populations at high risk for fracture. (See "Overview of the
management of osteoporosis in postmenopausal women", section on 'Other therapies'.)

Laboratory findings

Macroovalocytic anemia — The major hematologic finding in either Cbl or FA deficiency is a macroovalocytic
anemia (picture 1) with elevated levels of iron, indirect bilirubin, and LDH, and low levels of haptoglobin, reflecting
increased red cell breakdown due to both peripheral destruction and ineffective erythropoiesis. The absolute
reticulocyte count is normal or low, reflecting the inability of the hyperplastic bone marrow to produce and deliver red
cells effectively. The peripheral blood smear shows macroovalocytes, rarely occasionally megaloblasts, and
hypersegmented neutrophils (greater than 5 percent of neutrophils with five or more lobes or 1 percent with six or
more lobes) (picture 2). Macrocytosis (mean cell volume >100 fl) is not specific for Cbl or folate deficiency, and
hypersegmented neutrophils can also occur in renal failure, iron deficiency, or as a familial trait. However, the
combination of macrocytosis and hypersegmented neutrophils is pathognomonic of megaloblastic anemia (picture
2). (See "Macrocytosis".)

● When the anemia is severe, there may also be thrombocytopenia and neutropenia (ie, pancytopenia),
suggesting diagnoses such as the myelodysplastic syndrome/acute myeloid leukemia (MDS/AML), or aplastic
anemia, all of which may present with macrocytosis, reduced reticulocyte count, and pancytopenia. Careful
examination of the peripheral blood smear and bone marrow for dysplastic (eg, hyposegmented neutrophils) or
leukemic white blood cell changes is diagnostic in MDS/AML, while the marrow in aplastic anemia shows
markedly reduced cellularity. (See "Clinical manifestations and diagnosis of the myelodysplastic syndromes",
section on 'Diagnosis' and "Aplastic anemia: Pathogenesis; clinical manifestations; and diagnosis", section on

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'Diagnosis'.)

● Bone marrow aspiration and biopsy is usually not required, but when performed reveals a very hypercellular
marrow with megaloblastic erythroid hyperplasia, giant metamyelocytes, and many mitoses (picture 3).

● Assays of serum or red cell folate, serum B12, methylmalonate, and homocysteine are required to confirm the
diagnosis of folate and/or vitamin B12 deficiency. These tests and the strategy for making these diagnoses are
described separately. (See "Diagnosis and treatment of vitamin B12 and folate deficiency", section on 'Initial
diagnostic strategy'.)

Hyperhomocysteinemia — Both Cbl and folate are required for the metabolism of homocysteine to methionine
(figure 3). As a result, deficiencies in these vitamins can lead to elevations in plasma homocysteine levels, a risk
factor for the development of atherosclerosis and venous thromboembolism [13,75]. (See "Overview of
homocysteine".)

The importance of vitamin deficiency in the pathogenesis of hyperhomocysteinemia has been evaluated in a cohort
of 1041 older adult subjects [75]. Two-thirds of those with elevated homocysteine levels had a subnormal plasma
concentration of folate, vitamin B12, or pyridoxal-5-phosphate (the coenzyme form of vitamin B6). In this report,
homocysteine levels were inversely related to folate consumption, reaching a stable baseline level when the folate
intake exceeded 400 mcg/day.

FOLATE DEFICIENCY

Dietary intake and absorption — Food folates occur in animal products and in leafy vegetables (eg, green leafy
vegetables, fruits, cereals and grains, nuts, and meats) in the polyglutamate form [1,4]. Normal daily requirements
for unstressed individuals are about 200 to 400 mcg per day; this increases to 500 to 800 mcg per day in pregnancy
and lactation.

Folate at physiologic levels enters cells by binding to a folate receptor. Once inside the cell, FA is polyglutamated, a
form that is biologically active and cannot back diffuse into the plasma (figure 4) [30]. Polyglutamated
tetrahydrofolate participates in purine synthesis.

In countries such as the United States and Australia where folic acid fortification of flour is mandated, the prevalence
of folate deficiency has fallen.

● A study from Australia showed that between April 2009 and April 2010, the prevalence of folate deficiency
measured in over 20,000 blood samples fell by 77 percent from 9.3 percent to 2.1 percent [76].

● An review of outpatient serum folate testing in the United States between 2003 and 2013 (84,187 samples)
found folate deficiency in only 47 (0.06 percent), and low-normal levels in 166 (0.20 percent); the remainder
were normal or high [77].

● Two studies in adults age ≥65 years with anemia in the United States (190 and 174 patients) did not detect any
cases of folate deficiency [78,79].

Causes of folate deficiency

Poor nutrition and alcoholism — The most common cause of folate deficiency is nutritional, due to poor diet
and/or alcoholism (table 2). Although food folates are plentiful in liver, greens, and yeast, they are easily destroyed
by heat during cooking. Body stores are small (5 to 10 mg) and individuals on a folate-deficient diet can develop
megaloblastosis within four to five months.

● Older patients – As noted above for cobalamin deficiency, folate deficiency is also common in older adults. In
one study the age-specific prevalence of folate deficiency was approximately 5 and 10 percent in those ages
65 to 74 versus those ≥75 years of age, respectively [23]. Combined cobalamin and folate deficiency was
uncommon in this population.

● Alcohol abuse – Alcohol abuse produces a sharp fall in serum folate within two to four days by impairing its

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enterohepatic cycle and inhibiting its absorption [30]. Thus, alcoholics on a low folate intake can develop
megaloblastosis within 5 to 10 weeks. This period is shorter than the four to five months required in normals in
part because alcoholics start with lower stores due to previous dietary habits.

● Goat’s milk – The folate concentration in goat’s milk is markedly less than that in cow’s milk (1 versus 12
mcg/8 ounces). Accordingly, infants fed goat’s milk may develop folate deficiency, especially if other sources of
folate have not yet been introduced into the diet. Goat’s milk fortified with folic acid is commercially available to
avoid this problem.

Increased requirements — Other mechanisms of folate deficiency include increased requirements in pregnancy
and in patients with chronic hemolytic anemias, exfoliative skin disease, and drug-induced interference with folate
metabolism. Pregnancy and lactation increase the need for FA and the daily requirement increases from 400 mcg to
800 mcg [80]. Since early signs of deficiency may be subtle and intake is inadequate in some socioeconomic
groups, folic acid supplementation (0.8 to 1 mg/day) should be given prophylactically to all pregnant women. This
regimen also appears to prevent the development of neural tube defects [81]. The US Public Health Service
recommends that all women of childbearing age capable of becoming pregnant should consume 400 mcg of folic
acid daily to help prevent neural tube defects [82]. (See "Vitamin supplementation in disease prevention", section on
'Neural tube defects' and "Folic acid supplementation in pregnancy".)

Drugs — Several drugs interfere with FA metabolism:

● Trimethoprim is a weak inhibitor of dihydrofolate reductase and in high dose has been implicated in
megaloblastic pancytopenia.

● Pyrimethamine (Daraprim), an agent used for the treatment of malaria and toxoplasmosis, is an inhibitor of
parasitic dihydrofolate reductase, and has been associated with folate deficiency and megaloblastic anemia.

● Methotrexate can also produce folate deficiency. During thymidylate synthesis, folate becomes oxidized to
inactive dihydrofolate polyglutamate. Regeneration of active tetrahydrofolate requires the enzyme dihydrofolate
reductase, which is inhibited by methotrexate [83]. Treatment usually consists of FA in a dose of 1 mg/day
although up to 5 mg/day may be required. For reversal of the chemotherapeutic anti-fol effect of larger doses of
methotrexate, one uses folinic acid (leucovorin), which bypasses this enzymatic block. (See "Therapeutic use
and toxicity of high-dose methotrexate", section on 'Leucovorin administration'.)

● Phenytoin blocks FA absorption and increases utilization of FA by an unknown mechanism [30].

Hereditary folate malabsorption — Hereditary folate malabsorption is an extremely rare autosomal recessive
cause of folate deficiency [84]. It presents early in life with diarrhea, failure to thrive, megaloblastic anemia, and
progressive neurologic deterioration (ataxia, seizures, and mental retardation). Family studies have shown this
disorder to be due to mutations in a proton-coupled folate transporter (PCFT), resulting in abnormal folate transport
across the gastrointestinal tract and the blood-brain barrier [85-88].

Treatment with high-dose oral or parenteral folinic acid is effective, but serum folate levels needed to provide
adequate CNS concentrations of the vitamin are not known [89,90]. Serial neurocognitive developmental
examinations during childhood are needed in order to determine adequacy of treatment, since some of the
neurologic deficits can otherwise become permanent [84].

Other hereditary causes — Rare causes of folate deficiency include a number of congenital enzyme
deficiencies involving the metabolism of folate. These include methylenetetrahydrofolate reductase deficiency,
glutamate formiminotransferase deficiency, and functional methionine synthase deficiency [47].

Clinical presentation — The classic presentation of folate deficiency is quite different from that of Cbl deficiency.
The patient may abuse alcohol or other drugs and have a very poor dietary intake. Older and depressed patients
who live alone and avoid eating foods that contain folate may become deficient, as can patients with the
malabsorption syndrome. Increased folate demands occur in patients with chronic severe hemolytic anemia,
pregnancy, and exfoliative dermatitis, which may lead to folate deficiency (table 2) [80]. Folate deficiency is now less

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common in those countries where folic acid fortification of flour is mandated (Flour Fortification Initiative). (See "Folic
acid supplementation in pregnancy", section on 'Food fortification'.)

Deficiency of either Cbl or FA produces megaloblastic anemia. While Cbl deficiency is commonly associated with
neurologic changes, such as subacute combined degeneration of the spinal cord, cerebellar ataxia, axonal
degeneration of peripheral nerves, memory loss, irritability, dementia, and extrapyramidal signs, such neurologic
complications have been reported only rarely in patients with folate deficiency [91-93]. Exceptions to this general rule
are the rare cases of hereditary folate malabsorption and/or metabolism, which are associated with progressive
neurologic deterioration early in life [94]. (See 'Hereditary folate malabsorption' above.)

Another important difference between the two deficiencies is the time required for a deficiency to develop. Because
Cbl stores are so large in relation to daily intake, years of inadequate Cbl intake or absorption are required before
the onset of symptoms. On the other hand, symptoms of folate deficiency can occur within four to five months after
intake is diminished, since body stores of folate are relatively small (5 to 10 mg) in relation to daily requirements (200
to 400 mcg).

Laboratory findings — The general laboratory and hematologic findings are identical in Cbl and FA deficiency, and
hyperhomocysteinemia can occur in both conditions. The two deficiencies can coexist in some patients with
malabsorption, especially in those with tropical sprue. (See 'Laboratory findings' above.)

Assays of serum or red cell folate, serum B12, methylmalonate, and homocysteine are required to distinguish
between folate and vitamin B12 deficiency. These tests, and the strategy for making these diagnoses are described
separately. (See "Diagnosis and treatment of vitamin B12 and folate deficiency", section on 'Initial diagnostic
strategy'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the
10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient information: Vitamin B12 deficiency and folate (folic acid) deficiency (The Basics)"
and "Patient information: Pernicious anemia (The Basics)")

SUMMARY — Deficiency of either cobalamin (vitamin B12, Cbl) or folate (folic acid, FA) is classically associated
with the presence of megaloblastic anemia with ineffective erythropoiesis, but only Cbl deficiency is associated with
neurologic changes.

● Disease onset:

• Cbl stores (2 to 5 milligrams) are large in relation to the daily requirement for this vitamin (6 to 9 mcg/day).
Accordingly, years of inadequate Cbl intake or absorption are required before the onset of symptoms.

• Symptoms of FA deficiency can occur within four to five months after intake is diminished, since body
stores are smaller (5 to 10 mg) in relation to daily requirements (200 to 400 mcg).

● Causes – Cbl deficiency is most often due to inadequate absorption of this vitamin (table 1), whereas FA
deficiency is generally attributable to an inadequate diet and/or alcoholism (table 2). The two deficiencies can
coexist in some patients with malabsorption.

● Clinical manifestations (see 'General considerations' above):

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• Symptoms in Cbl deficiency are related to the anemia and/or neurologic changes (eg, memory loss,
irritability, dementia, and subacute combined degeneration). (See 'Neurologic changes' above.)

• Symptoms in FA deficiency are restricted to those associated with anemia.

● Laboratory manifestations – The major hematologic findings in either Cbl or FA deficiency are identical and
include macroovalocytic anemia (picture 1), elevated levels of iron, indirect bilirubin, and LDH, low levels of
haptoglobin and reticulocytes, and the presence of hypersegmented neutrophils (picture 2). (See 'Laboratory
findings' above.)

• Bone marrow aspiration and biopsy reveals a hypercellular marrow with megaloblastic erythroid
hyperplasia, giant metamyelocytes, and many mitoses (picture 3).

• Assays of serum or red cell FA, serum Cbl, methylmalonate, and homocysteine are required to distinguish
between Cbl and FA deficiency. These tests are described separately. (See "Diagnosis and treatment of
vitamin B12 and folate deficiency", section on 'Initial diagnostic strategy'.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Pruthi RK, Tefferi A. Pernicious anemia revisited. Mayo Clin Proc 1994; 69:144.
2. Allen RH, Stabler SP, Savage DG, Lindenbaum J. Metabolic abnormalities in cobalamin (vitamin B12) and
folate deficiency. FASEB J 1993; 7:1344.
3. Green R, Kinsella LJ. Current concepts in the diagnosis of cobalamin deficiency. Neurology 1995; 45:1435.
4. Tefferi A, Pruthi RK. The biochemical basis of cobalamin deficiency. Mayo Clin Proc 1994; 69:181.
5. Carmel R. Prevalence of undiagnosed pernicious anemia in the elderly. Arch Intern Med 1996; 156:1097.
6. Toh BH, van Driel IR, Gleeson PA. Pernicious anemia. N Engl J Med 1997; 337:1441.
7. Karlsson FA, Burman P, Lööf L, Mårdh S. Major parietal cell antigen in autoimmune gastritis with pernicious
anemia is the acid-producing H+,K+-adenosine triphosphatase of the stomach. J Clin Invest 1988; 81:475.
8. Amedei A, Bergman MP, Appelmelk BJ, et al. Molecular mimicry between Helicobacter pylori antigens and H+,
K+ --adenosine triphosphatase in human gastric autoimmunity. J Exp Med 2003; 198:1147.
9. Toh BH, Chan J, Kyaw T, Alderuccio F. Cutting edge issues in autoimmune gastritis. Clin Rev Allergy Immunol
2012; 42:269.
10. Bunn HF. Vitamin B12 and pernicious anemia--the dawn of molecular medicine. N Engl J Med 2014; 370:773.
11. Carmel R. How I treat cobalamin (vitamin B12) deficiency. Blood 2008; 112:2214.
12. Guéant JL, Safi A, Aimone-Gastin I, et al. Autoantibodies in pernicious anemia type I patients recognize
sequence 251-256 in human intrinsic factor. Proc Assoc Am Physicians 1997; 109:462.
13. Sumner AE, Chin MM, Abrahm JL, et al. Elevated methylmalonic acid and total homocysteine levels show high
prevalence of vitamin B12 deficiency after gastric surgery. Ann Intern Med 1996; 124:469.
14. Hu Y, Kim HI, Hyung WJ, et al. Vitamin B(12) deficiency after gastrectomy for gastric cancer: an analysis of
clinical patterns and risk factors. Ann Surg 2013; 258:970.
15. Kaptan K, Beyan C, Ural AU, et al. Helicobacter pylori--is it a novel causative agent in Vitamin B12 deficiency?
Arch Intern Med 2000; 160:1349.
16. Borén T, Falk P, Roth KA, et al. Attachment of Helicobacter pylori to human gastric epithelium mediated by
blood group antigens. Science 1993; 262:1892.
17. Hazra A, Kraft P, Selhub J, et al. Common variants of FUT2 are associated with plasma vitamin B12 levels.
Nat Genet 2008; 40:1160.
18. Azevedo M, Eriksson S, Mendes N, et al. Infection by Helicobacter pylori expressing the BabA adhesin is
influenced by the secretor phenotype. J Pathol 2008; 215:308.

10 of 24 1/25/2015 10:30 PM
Etiology and clinical manifestations of vitamin B12 and folate deficiency http://www.uptodate.com.libproxy.ucl.ac.uk/contents/etiology-and-clinic...

19. Lindenbaum J, Rosenberg IH, Wilson PW, et al. Prevalence of cobalamin deficiency in the Framingham elderly
population. Am J Clin Nutr 1994; 60:2.
20. van Asselt DZ, de Groot LC, van Staveren WA, et al. Role of cobalamin intake and atrophic gastritis in mild
cobalamin deficiency in older Dutch subjects. Am J Clin Nutr 1998; 68:328.
21. Rajan S, Wallace JI, Beresford SA, et al. Screening for cobalamin deficiency in geriatric outpatients:
prevalence and influence of synthetic cobalamin intake. J Am Geriatr Soc 2002; 50:624.
22. Figlin E, Chetrit A, Shahar A, et al. High prevalences of vitamin B12 and folic acid deficiency in elderly subjects
in Israel. Br J Haematol 2003; 123:696.
23. Clarke R, Grimley Evans J, Schneede J, et al. Vitamin B12 and folate deficiency in later life. Age Ageing 2004;
33:34.
24. Andrès E, Goichot B, Schlienger JL. Food cobalamin malabsorption: a usual cause of vitamin B12 deficiency.
Arch Intern Med 2000; 160:2061.
25. Andrès E, Loukili NH, Noel E, et al. Vitamin B12 (cobalamin) deficiency in elderly patients. CMAJ 2004;
171:251.
26. Dali-Youcef N, Andrès E. An update on cobalamin deficiency in adults. QJM 2009; 102:17.
27. Doscherholmen A, Swaim WR. Impaired assimilation of egg Co 57 vitamin B 12 in patients with
hypochlorhydria and achlorhydria and after gastric resection. Gastroenterology 1973; 64:913.
28. Schilling RF, Gohdes PN, Hardie GH. Vitamin B12 deficiency after gastric bypass surgery for obesity. Ann
Intern Med 1984; 101:501.
29. Shah M, Simha V, Garg A. Review: long-term impact of bariatric surgery on body weight, comorbidities, and
nutritional status. J Clin Endocrinol Metab 2006; 91:4223.
30. Anthony CA. Megaloblastic anemias. In: Hematology: Basic Principles and Practice, 2nd ed, Hoffman R, Benz
EJ, Shattil SJ, et al. (Eds), Churchill Livingston, New York 1995. p.552.
31. Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy causes malabsorption of cyanocobalamin
(vitamin B12). Ann Intern Med 1994; 120:211.
32. Valuck RJ, Ruscin JM. A case-control study on adverse effects: H2 blocker or proton pump inhibitor use and
risk of vitamin B12 deficiency in older adults. J Clin Epidemiol 2004; 57:422.
33. Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and histamine 2 receptor antagonist use
and vitamin B12 deficiency. JAMA 2013; 310:2435.
34. Allen LH. Vitamin B12 metabolism and status during pregnancy, lactation and infancy. Adv Exp Med Biol 1994;
352:173.
35. Balcı YI, Ergin A, Karabulut A, et al. Serum vitamin B12 and folate concentrations and the effect of the
Mediterranean diet on vulnerable populations. Pediatr Hematol Oncol 2014; 31:62.
36. Remacha AF, Cadafalch J. Cobalamin deficiency in patients infected with the human immunodeficiency virus.
Semin Hematol 1999; 36:75.
37. Tang AM, Graham NM, Chandra RK, Saah AJ. Low serum vitamin B-12 concentrations are associated with
faster human immunodeficiency virus type 1 (HIV-1) disease progression. J Nutr 1997; 127:345.
38. Tanner SM, Li Z, Perko JD, et al. Hereditary juvenile cobalamin deficiency caused by mutations in the intrinsic
factor gene. Proc Natl Acad Sci U S A 2005; 102:4130.
39. Ament AE, Li Z, Sturm AC, et al. Juvenile cobalamin deficiency in individuals of African ancestry is caused by
a founder mutation in the intrinsic factor gene GIF. Br J Haematol 2009; 144:622.
40. Aminoff M, Carter JE, Chadwick RB, et al. Mutations in CUBN, encoding the intrinsic factor-vitamin B12
receptor, cubilin, cause hereditary megaloblastic anaemia 1. Nat Genet 1999; 21:309.
41. Kristiansen M, Aminoff M, Jacobsen C, et al. Cubilin P1297L mutation associated with hereditary
megaloblastic anemia 1 causes impaired recognition of intrinsic factor-vitamin B(12) by cubilin. Blood 2000;
96:405.
42. Tanner SM, Aminoff M, Wright FA, et al. Amnionless, essential for mouse gastrulation, is mutated in recessive
hereditary megaloblastic anemia. Nat Genet 2003; 33:426.

11 of 24 1/25/2015 10:30 PM
Etiology and clinical manifestations of vitamin B12 and folate deficiency http://www.uptodate.com.libproxy.ucl.ac.uk/contents/etiology-and-clinic...

43. Fyfe JC, Madsen M, Højrup P, et al. The functional cobalamin (vitamin B12)-intrinsic factor receptor is a novel
complex of cubilin and amnionless. Blood 2004; 103:1573.
44. Andersen CB, Madsen M, Storm T, et al. Structural basis for receptor recognition of vitamin-B(12)-intrinsic
factor complexes. Nature 2010; 464:445.
45. Birn H, Fyfe JC, Jacobsen C, et al. Cubilin is an albumin binding protein important for renal tubular albumin
reabsorption. J Clin Invest 2000; 105:1353.
46. Nykjaer A, Fyfe JC, Kozyraki R, et al. Cubilin dysfunction causes abnormal metabolism of the steroid hormone
25(OH) vitamin D(3). Proc Natl Acad Sci U S A 2001; 98:13895.
47. Whitehead VM. Acquired and inherited disorders of cobalamin and folate in children. Br J Haematol 2006;
134:125.
48. Coelho D, Suormala T, Stucki M, et al. Gene identification for the cblD defect of vitamin B12 metabolism. N
Engl J Med 2008; 358:1454.
49. Rutsch F, Gailus S, Miousse IR, et al. Identification of a putative lysosomal cobalamin exporter altered in the
cblF defect of vitamin B12 metabolism. Nat Genet 2009; 41:234.
50. Carmel R, Parker J, Kelman Z. Genomic mutations associated with mild and severe deficiencies of
transcobalamin I (haptocorrin) that cause mildly and severely low serum cobalamin levels. Br J Haematol
2009; 147:386.
51. Quadros EV. Advances in the understanding of cobalamin assimilation and metabolism. Br J Haematol 2010;
148:195.
52. Coelho D, Kim JC, Miousse IR, et al. Mutations in ABCD4 cause a new inborn error of vitamin B12
metabolism. Nat Genet 2012; 44:1152.
53. Lesesve JF, Latger-Cannard V. Crucial microscopic features leading to diagnosis of cobalamin C deficiency in
a new-born. Br J Haematol 2013; 161:608.
54. Yu HC, Sloan JL, Scharer G, et al. An X-linked cobalamin disorder caused by mutations in transcriptional
coregulator HCFC1. Am J Hum Genet 2013; 93:506.
55. Puig A, Mino-Kenudson M, Dighe AS. Case records of the Massachusetts General Hospital. Case 13-2012. A
62-year-old man with paresthesias, weight loss, jaundice, and anemia. N Engl J Med 2012; 366:1626.
56. Stabler SP, Allen RH, Savage DG, Lindenbaum J. Clinical spectrum and diagnosis of cobalamin deficiency.
Blood 1990; 76:871.
57. Graells J, Ojeda RM, Muniesa C, et al. Glossitis with linear lesions: an early sign of vitamin B12 deficiency. J
Am Acad Dermatol 2009; 60:498.
58. Hemmer B, Glocker FX, Schumacher M, et al. Subacute combined degeneration: clinical, electrophysiological,
and magnetic resonance imaging findings. J Neurol Neurosurg Psychiatry 1998; 65:822.
59. Kumar S. Vitamin B12 deficiency presenting with an acute reversible extrapyramidal syndrome. Neurol India
2004; 52:507.
60. Sharrief AZ, Raffel J, Zee DS. Vitamin B(12) deficiency with bilateral globus pallidus abnormalities. Arch
Neurol 2012; 69:769.
61. Larner AJ. Visual failure caused by vitamin B12 deficiency optic neuropathy. Int J Clin Pract 2004; 58:977.
62. Pott JW, Wong KH. Leber's hereditary optic neuropathy and vitamin B12 deficiency. Graefes Arch Clin Exp
Ophthalmol 2006; 244:1357.
63. Tangney CC, Tang Y, Evans DA, Morris MC. Biochemical indicators of vitamin B12 and folate insufficiency and
cognitive decline. Neurology 2009; 72:361.
64. 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.
65. Kumar N. Copper deficiency myelopathy (human swayback). Mayo Clin Proc 2006; 81:1371.
66. Prodan CI, Bottomley SS, Vincent AS, et al. Hypocupremia associated with prior vitamin B12 deficiency. Am J
Hematol 2007; 82:288.
67. Dhonukshe-Rutten RA, Lips M, de Jong N, et al. Vitamin B-12 status is associated with bone mineral content

12 of 24 1/25/2015 10:30 PM
Etiology and clinical manifestations of vitamin B12 and folate deficiency http://www.uptodate.com.libproxy.ucl.ac.uk/contents/etiology-and-clinic...

and bone mineral density in frail elderly women but not in men. J Nutr 2003; 133:801.
68. Tucker KL, Hannan MT, Qiao N, et al. Low plasma vitamin B12 is associated with lower BMD: the Framingham
Osteoporosis Study. J Bone Miner Res 2005; 20:152.
69. Goerss JB, Kim CH, Atkinson EJ, et al. Risk of fractures in patients with pernicious anemia. J Bone Miner Res
1992; 7:573.
70. Merriman NA, Putt ME, Metz DC, Yang YX. Hip fracture risk in patients with a diagnosis of pernicious anemia.
Gastroenterology 2010; 138:1330.
71. Carmel R, Lau KH, Baylink DJ, et al. Cobalamin and osteoblast-specific proteins. N Engl J Med 1988; 319:70.
72. Kim GS, Kim CH, Park JY, et al. Effects of vitamin B12 on cell proliferation and cellular alkaline phosphatase
activity in human bone marrow stromal osteoprogenitor cells and UMR106 osteoblastic cells. Metabolism
1996; 45:1443.
73. Stone KL, Bauer DC, Sellmeyer D, Cummings SR. Low serum vitamin B-12 levels are associated with
increased hip bone loss in older women: a prospective study. J Clin Endocrinol Metab 2004; 89:1217.
74. Cagnacci A, Baldassari F, Rivolta G, et al. Relation of homocysteine, folate, and vitamin B12 to bone mineral
density of postmenopausal women. Bone 2003; 33:956.
75. Selhub J, Jacques PF, Wilson PW, et al. Vitamin status and intake as primary determinants of
homocysteinemia in an elderly population. JAMA 1993; 270:2693.
76. Brown RD, Langshaw MR, Uhr EJ, et al. The impact of mandatory fortification of flour with folic acid on the
blood folate levels of an Australian population. Med J Aust 2011; 194:65.
77. Theisen-Toupal J, Horowitz G, Breu A. Low yield of outpatient serum folate testing: eleven years of
experience. JAMA Intern Med 2014; 174:1696.
78. Price EA, Mehra R, Holmes TH, Schrier SL. Anemia in older persons: etiology and evaluation. Blood Cells Mol
Dis 2011; 46:159.
79. Artz AS, Thirman MJ. Unexplained anemia predominates despite an intensive evaluation in a racially diverse
cohort of older adults from a referral anemia clinic. J Gerontol A Biol Sci Med Sci 2011; 66:925.
80. McPartlin J, Halligan A, Scott JM, et al. Accelerated folate breakdown in pregnancy. Lancet 1993; 341:148.
81. Wald NJ, Bower C. Folic acid, pernicious anaemia, and prevention of neural tube defects. Lancet 1994;
343:307.
82. Centers for Disease Control (CDC). Locally acquired neurocysticercosis--North Carolina, Massachusetts, and
South Carolina, 1989-1991. MMWR Morb Mortal Wkly Rep 1992; 41:1.
83. Bertino JR. Karnofsky memorial lecture. Ode to methotrexate. J Clin Oncol 1993; 11:5.
84. Geller J, Kronn D, Jayabose S, Sandoval C. Hereditary folate malabsorption: family report and review of the
literature. Medicine (Baltimore) 2002; 81:51.
85. Qiu A, Jansen M, Sakaris A, et al. Identification of an intestinal folate transporter and the molecular basis for
hereditary folate malabsorption. Cell 2006; 127:917.
86. Zhao R, Min SH, Qiu A, et al. The spectrum of mutations in the PCFT gene, coding for an intestinal folate
transporter, that are the basis for hereditary folate malabsorption. Blood 2007; 110:1147.
87. Zhao R, Matherly LH, Goldman ID. Membrane transporters and folate homeostasis: intestinal absorption and
transport into systemic compartments and tissues. Expert Rev Mol Med 2009; 11:e4.
88. Salojin KV, Cabrera RM, Sun W, et al. A mouse model of hereditary folate malabsorption: deletion of the PCFT
gene leads to systemic folate deficiency. Blood 2011; 117:4895.
89. Kishimoto K, Kobayashi R, Sano H, et al. Impact of folate therapy on combined immunodeficiency secondary
to hereditary folate malabsorption. Clin Immunol 2014; 153:17.
90. Borzutzky A, Crompton B, Bergmann AK, et al. Reversible severe combined immunodeficiency phenotype
secondary to a mutation of the proton-coupled folate transporter. Clin Immunol 2009; 133:287.
91. Lever EG, Elwes RD, Williams A, Reynolds EH. Subacute combined degeneration of the cord due to folate
deficiency: response to methyl folate treatment. J Neurol Neurosurg Psychiatry 1986; 49:1203.
92. Green R, Miller JW. Folate deficiency beyond megaloblastic anemia: hyperhomocysteinemia and other

13 of 24 1/25/2015 10:30 PM
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manifestations of dysfunctional folate status. Semin Hematol 1999; 36:47.

93. Okada A, Koike H, Nakamura T, et al. Slowly progressive folate-deficiency myelopathy: report of a case. J
Neurol Sci 2014; 336:273.
94. Clayton PT, Smith I, Harding B, et al. Subacute combined degeneration of the cord, dementia and
parkinsonism due to an inborn error of folate metabolism. J Neurol Neurosurg Psychiatry 1986; 49:920.

Topic 7154 Version 31.0

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GRAPHICS

Role of cobalamin (vitamin B12) in homocysteine and

methylmalonic acid metabolism

Role of cobalamin in homocysteine and methylmalonic acid metabolism. Panel A -

Methylcobalamin is a cofactor in the synthesis of methionine from homocysteine. Panel
B - Adenosylcobalamin is a cofactor in the synthesis of succinyl-CoA from
methylmalonyl-CoA. Tetrahydrofolate (THF) participates in homocysteine but not
methylmalonic acid (MMA) metabolism. Thus, cobalamin deficiency is characterized by
elevations in the serum levels of both homocysteine and MMA, while only homocysteine
levels are elevated in folate deficiency.

Reproduced with permission from Tefferi, A, Pruthi, RK. The Biochemical Basis of Cobalamin
Deficiency. Mayo Clin Proc 1994; 69:181

Graphic 58245 Version 2.0

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Causes of vitamin B12 deficiency

Gastric abnormalities
Pernicious anemia

Gastrectomy/bariatric surgery

Gastritis

Autoimmune metaplastic atrophic gastritis

Small bowel disease

Malabsorption syndrome

Ileal resection or bypass

Crohn's disease

Blind loops

Diphyllobothrium latum (fish tapeworm) infestation

Pancreatitis
Pancreatic insufficiency

Diet
Strict vegans

Vegetarian diet in pregnancy

Agents that block or inhibit absorption

Neomycin

Biguanides (eg, metformin)

Proton pump inhibitors (eg, omeprazole)

Histamine 2 receptor antagonists (eg, cimetidine)

N2O anesthesia inhibits methionine synthase

Inherited transcobalamin II deficiency

Graphic 77437 Version 4.0

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The Schilling test (part one)

Step 1: One µg of radioactive crystalline B12 is taken orally. Step 2:

Gastric acid and pepsin free vitamin B12 from food proteins. This step is
not required when crystalline B12 is utilized as the test dose. B12
attaches to "R" binders (R) produced by the stomach, which have a
higher affinity for B12 than intrinsic factor (IF), also produced by the
stomach. Step 3: Pancreatic proteases degrade the "R" binders,
allowing formation of the B12-IF complex, the specific form absorbed by
the terminal ileum. Step 4: One hour after the test dose, a 1000 µg
"flushing" dose of non-radioactive B12 is given to saturate B12 binders
(transcobalamines). Step 5: If present, bacteria in "blind loops" in the
duodenum or jejunum preferentially utilize vitamin B12, allowing none
to be available at the site of absorption. Step 6: With blood and tissue
B12 binding sites blocked by the "flushing" dose, the B12/IF complex is
absorbed by the terminal ileum, and the B12 is excreted in the urine
(step 7), which is assayed for its content of radioactivity. The test can
be repeated with the addition of missing factors (eg, intrinsic factor,
pancreatic extract), or following the use of nonabsorbable antibiotics
(blind loops and/or bacterial overgrowth present), or gluten-free diet
(celiac disease).
Note: While the Schilling test is rarely used today, steps 2, 3, and 6, as
described above, delineate the normal pathway for B12 absorption.

Graphic 72051 Version 3.0

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Macroovalocytes in vitamin B12 deficiency

Peripheral smear shows marked macroovalocytosis in a patient with

vitamin B12 deficiency. In this case teardrop cells are an advanced form
of macroovalocytes.

Courtesy of Stanley L Schrier, MD.

Graphic 74901 Version 4.0

Normal peripheral blood smear

High power view of a normal peripheral blood smear. Several

platelets (black arrows) and a normal lymphocyte (blue arrow) can
also be seen. The red cells are of relatively uniform size and shape.
The diameter of the normal red cell should approximate that of the
nucleus of the small lymphocyte; central pallor (red arrow) should
equal one-third of its diameter.

Courtesy of Carola von Kapff, SH (ASCP).

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Megaloblastic blood picture

Peripheral blood smear showing a hypersegmented neutrophil (seven

lobes) and macroovalocytes, a pattern that can be seen with cobalamin
or folate deficiency.

Courtesy of Stanley L Schrier, MD.

Graphic 58820 Version 2.0

Normal peripheral blood smear

High power view of a normal peripheral blood smear. Several

platelets (black arrows) and a normal lymphocyte (blue arrow) can
also be seen. The red cells are of relatively uniform size and shape.
The diameter of the normal red cell should approximate that of the
nucleus of the small lymphocyte; central pallor (red arrow) should
equal one-third of its diameter.

Courtesy of Carola von Kapff, SH (ASCP).

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Megaloblastic erythropoiesis

Comparison of normal and megaloblastic erythropoiesis with respect to

erythroid precursors in the bone marrow. Left panel: Normal
erythropoiesis. Right panel: Megaloblastic erythropoiesis.

Courtesy of Stanley L Schrier, MD.

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Pathways of homocysteine metabolism

Homocysteine is metabolized by one of two divergent pathways: transsulfuration; and

remethylation. The transsulfuration of homocysteine to cysteine is catalyzed by
cystathionine-β-synthase (CBS), a process that requires pyridoxal phosphate (vitamin
B6) as a cofactor. Remethylation of homocysteine produces methionine. This reaction
is catalyzed either by methionine synthase or by betaine-homocysteine
methyltranferase. Vitamin B12 (cobalamin) is the precursor of methylcobalamin,
which is the cofactor for methionine synthase.

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Effects of cobalamin and folic acid on DNA synthesis

Interdependent cofactor activity of cobalamin and folate in intracellular DNA synthesis

and metabolism. The + signs indicate enhancement, and the - signs indicate inhibition.
Demethylation of methyl-tetrahydrofolate (CH3-THF) to THF is a critical step in DNA
synthesis because THF is the substrate for the enzyme that converts (THF)-1 to the
polyglutamated form (THF)n. Only polyglutamated (THF)n participates in purine
synthesis.

Reproduced with permission from Tefferi, A, Pruthi, RK. The Biochemical Basis of Cobalamin
Deficiency. Mayo Clin Proc 1994; 69:181

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Causes of folate (folic acid) deficiency

Nutritional deficiency
Substance abuse

Alcoholism

Poor dietary intake

Overcooked foods

Depressed patients

Nursing homes

Malabsorption
Celiac disease (sprue)

Inflammatory bowel disease

Infiltrative bowel disease

Short bowel syndrome

Drugs (various mechanisms)

Methotrexate

Trimethoprim

Ethanol

Phenytoin

Increased requirements
Pregnancy, lactation

Chronic hemolysis

Exfoliative dermatitis

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Disclosures
Disclosures: Stanley L Schrier, MD Nothing to disclose. William C Mentzer, MD Equity Ownership/Stock Options: Johnson & Johnson
[Anemia (Erythropoietin)]. Jennifer S Tirnauer, MD Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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