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Practice

Pernicious anemia presenting as glossitis

Akira Kobayashi and Hiromichi Iwasaki
CMAJ April 20, 2020 192 (16) E434; DOI: https://doi.org/10.1503/cmaj.191331
Akira Kobayashi
Division of Internal Medicine (Kobayashi), Nanmei-kai Miyagami Hospital, Kagoshima, Japan; Department of Infection Control and Prevention (Iwasaki), University of Fukui, Fukui, Japan
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Hiromichi Iwasaki
Division of Internal Medicine (Kobayashi), Nanmei-kai Miyagami Hospital, Kagoshima, Japan; Department of Infection Control and Prevention (Iwasaki), University of Fukui, Fukui, Japan
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A 69-year-old Japanese woman presented with a 4-week history of painful tongue and reduced sense of taste. On physical examination, she had a smooth, red tongue without dorsal papillae, suggestive of glossitis (Figure 1A). Results from laboratory tests were consistent with macrocytosis without anemia: mean corpuscular volume 104.9 (normal range 80–97) fL, hemoglobin 121 (normal range 110–165) mmol/L, iron 10.92 (normal range 8.95–26.85) μmol/L, ferritin 72 (normal range 5–157) μg/L and serum vitamin B12 77.49 (normal range 147.6–442.8) pmol/L. In addition, an endoscopic biopsy of her gastric mucosa showed atrophic gastritis, and the result from a test for the presence of serum anti-intrinsic antibodies was positive. We diagnosed pernicious anemia.

Figure 1:
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Figure 1:

(A) View of the tongue of a 69-year-old woman in Japan with pernicious anemia presenting as glossitis (smooth and red dorsum of the tongue, without lingual papillae). (B) One month after starting treatment with methylcobalamin, her tongue appears normal.

Pernicious anemia is a macrocytic anemia caused by vitamin B12 deficiency that results from a lack of intrinsic factor. Lack of intrinsic factor may be caused by atrophic gastritis and damage to the oxyntic mucosa and parietal cells, which normally produce hydrochloric acid and intrinsic factor.1 Glossitis presents in up to 25% of people with pernicious anemia, initially as bright red plaques that may evolve into atrophy of the lingual papillae.2 Oral manifestations of pernicious anemia, including glossitis and stomatitis, may occur in the absence of anemia and represent an early clinical sign of vitamin B12 deficiency.3 Other causes of glossitis include nutritional deficiencies of vitamin B12, folic acid, riboflavin and niacin.4

We prescribed intramuscular methylcobalamin for our patient’s pernicious anemia, and her painful tongue and reduced sense of taste resolved within days. Her tongue regained its normal appearance within a month (Figure 1B). She remains on maintenance therapy with intramuscular methylcobalamin.

Footnotes

  • Competing interests:

  • This article has been peer reviewed.

  • The authors have obtained patient consent.

References

  1. ↵
    1. Lahner E,
    2. Annibale B
    . Pernicious anemia: new insights from a gastroenterological point of view. World J Gastroenterol 2009;15:5121–8.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Graells J,
    2. Ojeda RM,
    3. Muniesa C,
    4. et al
    . Glossitis with linear lesions: an early sign of vitamin B12 deficiency. J Am Acad Dermatol 2009;60:498–500.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Field EA,
    2. Speechley JA,
    3. Rugman FR,
    4. et al
    . Oral signs and symptoms in patients with undiagnosed vitamin B12 deficiency. J Oral Pathol Med 1995;24:468–70.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Reamy BV,
    2. Derby R,
    3. Bunt CW
    . Common tongue conditions in primary care. Am Fam Physician 2010;81:627–34.
    OpenUrlPubMed
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Canadian Medical Association Journal: 192 (16)
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Vol. 192, Issue 16
20 Apr 2020
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Pernicious anemia presenting as glossitis
Akira Kobayashi, Hiromichi Iwasaki
CMAJ Apr 2020, 192 (16) E434; DOI: 10.1503/cmaj.191331

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Pernicious anemia presenting as glossitis
Akira Kobayashi, Hiromichi Iwasaki
CMAJ Apr 2020, 192 (16) E434; DOI: 10.1503/cmaj.191331
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