Knowledge Check

True or false: Neurologic manifestations may be the earliest and often the only manifestation of vitamin B12 deficiency.

In fact, the severity of the hematologic and neurologic manifestations appears to be inversely related in a particular patient.

What is subacute combined degeneration?

A peripheral neuropathy
A myelopathy
The neurologic features typically include a spastic paraparesis, extensor plantar response, and impaired perception of position and vibration.

Vitamin B12 deficiency may cause which of the following (see next slide for more information):

Peripheral neuropathy
Typical presentation is symmetrical distal sensory symptoms and signs usually beginning in the feet, spreading to the hands.
Myelopathy (spinal cord involvement)
Optic nerve changes
Psychiatric/cognitive changes

True or false: Both iron deficiency and vitamin B12 deficiency may cause glossitis (see next slide for more information).

Correct. Both deficiency states may cause atrophic glossitis, characterized by erythematous tongue, lack of lingual papillae, and a smooth, shiny, dry appearance.

Atrophic glossitis (also known as smooth tongue)

In early disease, the tongue papillae initially redden and may enlarge. In late disease, the tongue takes on an atrophic and smooth, beefy red appearance. Atrophic glossitis caused by nutritional deficiency often causes a painful sensation in the tongue.

Causes include:

  • Nutritional deficiencies of:
    • Iron
    • Folic acid
    • Vitamin B12
    • Riboflavin
    • Niacin
  • Systemic infection (e.g., syphilis)
  • Localized infection (e.g., Candida)
  • Amyloidosis
  • Celiac disease
  • Protein-calorie malnutrition
  • Xerostomia triggered by some medications and Sjögren syndrome

Iron deficiency anemia:

  • Glossitis common.
  • Often has early manifestations with atrophy of the filiform and fungiform papillae.
  • The atrophy may begin on the tip and lateral aspect of the tongue and eventually spread to involve the entire tongue surface.
  • Iron supplements will often reverse these changes.

Vitamin B12 deficiency:

  • May result in tongue changes with eventual atrophy and even ulceration.
  • These changes are indistinguishable from diseases of malabsorption and iron deficiency.
  • Clinically, burning pain on the tongue is often present before physical changes to the tongue.
  • As the disease worsens, there is a progressive, beefy red change to the tongue.
  • Late-stage disease is characterized by atrophy of the filiform and fungiform papilla and a smooth, glistening appearance.
  • Taste and smell alteration occurs in late disease.

Learn more here.

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