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Reversible Marked Splenomegaly in Pernicious Anemia
- Rajiv K. Pruthi, MD;
- Ayalew Tefferi, MD; and
- Robert M. Petitt, MD
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TO THE EDITOR:
Pernicious anemia is characterized by macrocytosis, neuropathy, and mucosal atrophy of the gastrointestinal tract, but marked splenomegaly is not considered to be a characteristic. We describe a patient with a marked enlargement of the spleen that resolved after vitamin B12 therapy.
In September 1991, a 46-year-old white man presented with fatigue. Physical findings included pallor and splenomegaly palpable at 8 cm below the left costal margin. Laboratory findings showed pancytopenia and macrocytosis. The patient had a leukocyte count of 2.0 109, with a normal differential; a hemoglobin concentration of 57 g/L; a mean corpuscular volume of 119 fL; a platelet count of 141 109/L; a total bilirubin of 2.1 mg/dL, with a normal direct fraction (other liver function tests were normal); and a lactic dehydrogenase level of 2940 U/L. A peripheral blood smear contained oval macrocytes and hypersegmented neutrophils, and the patient's bone marrow showed characteristic megaloblastic changes. The diagnosis was confirmed with an undetectable vitamin B12, normal serum folate, positive intrinsic factor antibody, and Schilling test. The splenomegaly and pancytopenia resolved 3 months after initiation of vitamin B12 therapy.
In the first half of the century, the reported incidence of splenomegaly in pernicious anemia varied from 3% to 45% [1-3], and the size ranged from 3 to 14 cm below the left costal margin [3]. Palpable splenomegaly in patients with pernicious anemia reportedly declined after the introduction of liver therapy in 1926 [1, 4]. Subsequently, Bigg [2] reported an incidence of 3% (6 of 200 patients). Of the 6 patients, 2 had no other condition that could account for the observed splenomegaly. In one of these patients, the spleen size regressed with treatment.
Thus, splenomegaly is probably a consistent feature of protracted, untreated pernicious anemia, which is now rare due to earlier recognition and institution of specific replacement therapy. Unlike in a previously reported case [5], the splenomegaly seen in our patient was totally reversed with vitamin B12 therapy. We conclude therefore that although marked splenomegaly may occur in pernicious anemia, it is both rare and reversible with treatment.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
Include no more than 300 words of text, three authors, and five references
Type with double-spacing
Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright 2004 by the American College of Physicians
