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CPE-009 · synthetic case B12-FX-20
Pancytopenia with MCV 112
A severe picture.
Purpose: A severe picture.
Inputs the engine received
Laboratory
- Serum vitamin B12
- 95 pg/mL
- MCV
- 112 fL
- Hemoglobin
- 6.8 g/dL
- Pancytopenia
- Yes
Patient
- Age
- 59 years
- Sex
- Male
What the engine reports
A severe megaloblastic anemia can mimic thrombotic microangiopathy. Urgent hematology review is needed; the routine outpatient pathway is not appropriate.
Detected clinical pattern
Urgent Review Finding
A safety rule calls for urgent clinical assessment. Read the safety findings first.
- B12 level: B12 95 pg/mL · low
- Pattern: b12 deficiency pattern
Why this pattern was identified
- Low serum B12. 95 pg/mL is below 200 pg/mL (148 pmol/L).
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Urgent hematology review.
- 2Look for the cause: pernicious anemia, diet, drugs (metformin, acid suppression, nitrous oxide) and malabsorption.
- 3Check B12 and folate, a reticulocyte count and a blood film; review alcohol, liver and thyroid status and drugs.
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).
Evidence and rule trace · 3 rules
B12-01Low serum B12
Inputs: serum B12 95 pg/mL (<200)
Biochemical pattern compatible with vitamin B12 deficiency.
B12-15Severe or hemolytic picture
Inputs: pancytopenia · hemoglobin 6.8 g/dL
Urgent hematology review.
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-STABLER-2013 · Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-160.
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
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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