Very unusual presentation of pernicious anemia with schistocytes in peripheral blood

摘要

A 36-year-old man without any relevant past medical history presented with asthenia for 3 to 4 weeks. A physical examination showed pale conjunctivae and skin. An automatic blood cell count revealed advanced anemia (hemoglobin, 58 g/L), high mean cell volume (129 fL), low white blood cell count (3.3 × 109/L), and normal platelet count. Reticulocyte values were 72 × 109/L. A peripheral blood (PB) film revealed anisocytosis, red blood cell fragments (panel A), some bite cells (panel B, arrows), and oval macrocytes. Serum lactate dehydrogenase levels were elevated (3100 U/L) and the bilirubin value was 1.8 mg/dL. Coagulation parameters were normal and direct antiglobulin test was negative. Microangiopathic hemolytic anemia (MAHA) was suspected. On reevaluation, his vitamin B12 value was low (150 pg/mL [normal, 250-1050]) and ADAMTS13 testing was 70%. The presence of antiintrinsic factor antibodies was confirmed, and gastrointestinal endoscopy revealed atrophic gastritis.