Journal of Advanced Clinical and Research Insights

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Hyperpigmentation of palms - A clue to B12 deficiency
  JCRI
CASE REPORT
Hyperpigmentation of palms - A clue to B12 deficiency
Vinoth Boopathy1, Padhmini Balasubramanian2
1Department of Medical Gastroenterology, Aarupadai Veedu Medical College and Hospital, Pondicherry, India
2Department of Radiodiagnosis, Aarupadai Veedu Medical College and Hospital, Pondicherry, India
Correspondence: Dr. Vinoth Boopathy,Department of Medical Gastroenterology, Aarupadai Veedu Medical College and Hospital, Pondicherry, India.
Phone: +91-9940817590.
E-mail: drbvinoth@gmail.com
Received 15 December 2017;
Accepted 22 February 2017
doi: 10.15713/ins.jcri.200
 
ABSTRACT
B12 deficiency anemia is commonly seen in elderly people who are pure vegetarians, especially in those who even avoids milk consumption. Hyperpigmentation of the palms is one of the common clinical manifestations of B12 deficiency, and here, we report such a case of B12 deficiency who presented with hyperpigmented palms.
Keywords:B12 deficiency,hyperpigmentation of palms,increased MCV
How to cite this article: Boopathy V, Balasubramanian P.Hyperpigmentation of palms - A clue to B12 deficiency. J AdvClin Res Insights 2018; 5: 22-22.
 
 

Introduction

Anemia is common in elderly people due to various reasons such as poor nutrition, use of non-steroidal anti-inflammatory drugs for cardiac ailments, and the increasing incidence of intestinal malignancies. Evaluating anemia is, hence, challenging and requires a careful history taking and a careful physical examination apart from routine laboratory investigations. In certain cases like B12 deficiency presence of hyperpigmentation of palms and soles, if present can provide an important clue to the etiology of anemia. We present this case to emphasis the importance of history taking and careful examination of patients presenting with anemia.

Case Discussion

A 47-year-old male presented with h/o lassitude, weakness, and exertional dyspnea of 3 months duration. He stopped eating non-vegetarian diet for the past 3 years including milk due to religious reasons. On examination, there were pallor, glossitis, and angular stomatitis. He also had hyperpigmentation of the palmar aspect of the both hands [Figure 1a]. Investigations showed hemoglobin of 6.9 g/dL with MCV of 120 fls and peripheral smear showed hypersegmented neutrophils with megaloblastic changes of the red blood cell. Gastroscopy was normal except for pale gastrointestinal mucosa. B12 deficiency was suspected in view of his dietary habit and megaloblastic anemia. The diagnosis was confirmed when his B12 level was tested to be low with a value of < 83 pg/dL (normal range being 180-900 pg/dL) which was most likely secondary to nutritional deficiency. Folic acid and iron levels were normal. Following B12 correction, his hyperpigmentation resolved [Figure 1b]and his hemoglobin level after 2 months was 10.5 g/dL and the patient was symptomatically better.

 
Discussion

Hyperpigmentation of palms is one of the common manifestations of B12 deficiency and in a patient with megaloblastic anemia provides an important clue to the diagnosis of B12 deficiency.[1,2] The mechanism of hyperpigmentation in B12 is complex and poorly understood. The two more accepted hypotheses are increased melanin synthesis and defective melanin transfer from melanocytes to adjacent megaloblastic keratinocytes.[3] The hyperpigmentation is often reversible with correction of B12 deficiency as seen in our patient.

Journal of Advanced Clinical & Research Insights, January-February, Vol 5, 201821

Boopathy and Balasubramanian Hyperpigmentation of palms

Hyperpigmentation of palms - A clue to B12 deficiency
Figure 1: Hyperpigmentation of the palms in patient with B12deficiency before treatment (a) and complete resolution of thehyperpigmentation after B12 correction (b)

 
References
  1. Demir N, Dogan M, Koc A, Kaba S, Bulan K, Ozkol HU, et al.Dermatological findings of vitamin B12 deficiency and resolvingtime of these symptoms. Cutan Ocul Toxicol 2014;33:70-3.
  2. Brescoll J, Daveluy S. A review of vitamin B12 in dermatology.Am J Clin Dermatol 2015;16:27-33.
  3. Speeckaert R, Van Gele M, Speeckaert MM, Lambert J,van Geel N. The biology of hyperpigmentation syndromes.Pigment Cell Melanoma Res 2014;27:512-24.

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