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CPE-009 · synthetic case B12-FX-07
Macrocytosis in a patient with alcohol use disorder
MCV 104, B12 not measured.
Purpose: MCV 104, B12 not measured.
Inputs the engine received
Laboratory
- MCV
- 104 fL
- Hemoglobin
- 13.5 g/dL
Patient
- Age
- 46 years
- Sex
- Male
Drugs, diet and risk groups
- Alcohol use disorder
- Yes
What the engine reports
Detected clinical pattern
Macrocytosis — Work-Up Needed
Macrocytosis has B12 and folate causes and many others.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Check B12 and folate, a reticulocyte count and a blood film; review alcohol, liver and thyroid status and drugs.
- 2Consider a vitamin B12 measurement.
Differentials, pitfalls and contradicting signals
- Macrocytosis has many causes beyond B12 and folate: alcohol, liver disease, hypothyroidism, reticulocytosis, myelodysplasia and drugs (hydroxyurea, methotrexate, zidovudine, azathioprine).
Missing information
- Vitamin B12 level.
Evidence and rule trace · 3 rules
B12-11Higher-risk group without B12 on file
Inputs: alcohol use disorder
Screening opportunity: a higher-risk group has no B12 measurement.
Evidence
- EV-BSH-2014 · Devalia V, Hamilton MS, Molloy AM; British Committee for Standards in Haematology. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol. 2014;166(4):496-513.
- EV-GREEN-2017 · Green R, Allen LH, Bjørke-Monsen AL, et al. Vitamin B12 deficiency. Nat Rev Dis Primers. 2017;3:17040.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety considerations. It does not diagnose, find the cause, or select a vitamin product, dose or route. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Serum B12 level
○ Below 200 pg/mL
Deficiency pattern
○ 200 to 300 pg/mL
Borderline: MMA and homocysteine settle it
○ Above 300 pg/mL
Deficiency unlikely, not excluded
No stage is assigned for the values entered.
Laboratory
- <200
- 200–300
- >300
Patient
Neurologic features
Drugs, diet and risk groups
More b12 cases
B12-FX-01
B12 of 150 pg/mL with macrocytic anemia
A 67-year-old with MCV 108.
B12-FX-02
Borderline B12 with raised MMA
B12 260 and MMA 0.52.
B12-FX-03
Borderline B12 and no confirmatory test
B12 250.
B12-FX-04
Macrocytic anemia, folic acid ordered, no B12
A safety situation.
B12-FX-05
Neuropathy, B12 220 and metformin for five years
Neurologic features with a borderline level.
B12-FX-06
Posterior-column signs and spasticity
A pattern compatible with subacute combined degeneration.
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