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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 59-year-old woman with a history of type 2 diabetes mellitus&#44; hypertension&#44; and gout who was receiving treatment with metformin&#44; valsartan&#44; enalapril&#44; and allopurinol&#46; She consulted a dermatologist 1 month after developing hyperpigmented macules&#46; While the lesions appeared initially on the palms of the hands and soles of the feet&#44; the patient subsequently developed widespread cutaneous involvement&#44; predominantly in intertriginous areas &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Of particular note were hyperpigmented macules on the lips and longitudinal melanonychia on the fingernails &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The differential diagnosis was lichen planus pigmentosus-inversus or an adverse drug reaction of the liquenoide type&#46; Two skin biopsies showed a superficial spongiotic and psoriasiform perivascular dermatitis with eosinophils&#44; consistent with an adverse drug reaction&#46; On follow-up at 6 months&#44; the patient presented mucocutaneous jaundice&#44; asthenia&#44; and dyspnea at rest&#46; A series of tests were ordered and the results revealed severe megaloblastic anemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the etiologic study&#44; high titers of antibodies to parietal cells and intrinsic factor were found&#44; and upper digestive tract endoscopy showed chronic atrophic inflammation of the gastric mucosa&#46; The results of the following tests were normal&#58; iron&#44; folate&#44; cortisol&#44; thyroid-stimulating hormone&#44; free thyroxine&#44; rapid plasma reagin&#44; and serological assays for human immunodeficiency virus&#44; hepatitis B virus&#44; and hepatitis C virus&#46; Treatment with intravenous vitamin B12 was started&#46; The patients progressed satisfactorily&#44; with partial regression of the skin lesions and complete remission of hematologic abnormalities after 5 months of follow-up &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Vitamin B12 plays an important role in the synthesis of DNA and RNA&#44; acting as an enzyme cofactor&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Onset of vitamin B12 deficiency is usually subacute&#44; starting when the body&#39;s reserves are exhausted&#46; The deficiency can be caused by a range of nutritional problems&#44; including a lack of intrinsic factor&#44; achlorhydria&#44; ileal disease&#44; malnutrition&#44; and malabsorption syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Diagnosis and treatment are of great clinical importance&#44; mainly because of the progressive hematologic and neurologic involvement&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The following cutaneous manifestations have been described&#58; generalized hyperpigmentation&#44; glossitis&#44; nail abnormalities&#44; and premature graying&#46; Hyperpigmentation is often more pronounced on the limbs&#44; primarily on the dorsum of the hands and feet&#44; in flexural areas&#44; and occasionally on the nails&#44; tongue&#44; and oral mucous membranes&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Since hyperpigmentation is a nonspecific symptom&#44; a broad range of differential diagnoses should be considered in such cases&#58; diabetes mellitus&#44; Addison disease&#44; Cushing syndrome&#44; post-inflammatory lesions&#44; amyloidosis&#44; melanosis of the skin&#44; heavy metal deposition&#44; thyroid disease&#44; tumors&#44; drug reactions&#44; and porphyria cutanea tarda&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The pathophysiology of hyperpigmentation is still a matter of debate&#46; The first hypothesis was proposed by Gilliam and Cox&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> who reported that patients with vitamin B12 deficiency had decreased levels of reduced glutathione &#40;GSH&#41;&#46; It is known that GSH inhibits tyrosinase activity and consequently melanogenesis&#46; Low levels of GSH permit increased tyrosinase activity&#44; and thereby favor an increase in melanogenesis&#46; Griepp<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> proposed a hypothesis involving biopterin&#44; a substance essential to the hydroxylation of phenylalanine&#46; Given the role of phenylalanine in the synthesis of melanin&#44; high levels of this amino acid could explain hyperpigmentation&#46; Marks<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> hypothesized that a change in the location and distribution of melanin might be involved&#44; observing that megaloblastic anemia is associated with a defect in the transport of melanin and its incorporation into keratinocytes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Accurate recognition of the cutaneous manifestations and eventual systemic involvement is essential in establishing a diagnosis&#46; Blood tests may reveal macrocytosis&#44; immature nuclei&#44; and hypersegmented granulocytes&#46; There may be an increase in levels of serum bilirubin and lactate dehydrogenase&#44; as occurred in the present case&#46; The sensitivity of low serum vitamin B12 concentrations &#40;&#60;&#160;200<span class="elsevierStyleHsp" style=""></span>&#40;g&#47;mL&#41; ranges from 65&#37; to 95&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> making it necessary to complement this finding with other tests having greater sensitivity&#46; Levels of methylmalonic acid higher than 400<span class="elsevierStyleHsp" style=""></span>nmol&#47;L and homocysteine above 21<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L have a sensitivity of 98&#37; and 96&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Once the diagnosis is confirmed&#44; the cause of the deficiency should be investigated&#46; In severe cases&#44; it should be remembered that the most common cause of vitamin B12 deficiency is autoimmune gastritis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patient&#44; further tests and explorations revealed high titers of antibodies against parietal cells and intrinsic factor and chronic atrophic inflammation of the gastric mucosa&#46; These findings supported a diagnosis of autoimmune gastritis&#46; However&#44; it should be noted that the patient was receiving treatment with metformin&#44; a drug that has been associated with decreased serum levels of vitamin B12&#46; A recent meta-analysis found treatment with metformin to be significantly associated with an increased incidence of vitamin B12 deficiency and reduced serum levels&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> It is therefore possible that the etiology in this case may have been twofold&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Histology may reveal epidermal thinning&#44; vacuolar changes and nuclear elongation of keratinocytes&#44; increases in the number of melanocytes in basal layers&#44; and the presence of numerous melanophages in the papillary dermis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;9</span></a> Electron microscopy will show intracytoplasmic desmosomes&#44; numerous aggregated bundles of tonofilaments in the cytoplasm of keratinocytes&#44; and highly condensed keratohyalin granules&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In the present case&#44; the results of the 2 histological studies carried out were not consistent with the findings described above and were&#44; rather&#44; indicative of an adverse drug reaction&#46; The possible complementary role in the etiology of 1 of this patient&#39;s medications could explain these findings&#44; and the histological changes associated with the drug reaction may have masked those more often found in cases of vitamin B12 deficiency&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Recommended treatment is based on the administration of vitamin B12 either orally&#44; intravenously&#44; or intramuscularly&#59; a number of management protocols exist&#46; In a randomized clinical trial comparing oral and parenteral therapy&#44; both groups showed similar reductions in mean corpuscular volume and increases in hematocrit at 4 months&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The present case highlights the causal relationship between vitamin B12 deficiency and generalized skin hyperpigmentation&#44; an association that presents a wide variety of dermatological manifestations&#46; Clinical suspicion plays a fundamental role in the diagnostic process&#44; and is higher in patients at higher risk&#44; including vegetarians&#44; malnourished patients&#44; older people&#44; and patients who have malabsorption syndromes or have undergone gastrectomy or bariatric surgery&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Vera-Kellet C&#44; Andino-Navarrete R&#44; Navajas-Galimany L&#46; D&#233;ficit de vitamina B12 y sus diversas manifestaciones dermatol&#243;gicas&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;762&#8211;764&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0&#8211;5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hemoglobin &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#8211;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hematocrit &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#8211;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mean corpuscular volume &#40;fL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">114&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#8211;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reticulocytes &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&#8211;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Serum B12 levels &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">559&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">200&#8211;900&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anisocytosis&#44; polychromasia&#44; macrocytosis&#44; dacrocyte&#44; hypersegmented neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypochromia&#44; polychromasia&#44; microcytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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Letter to the Editor
Vitamin B12 Deficiency and its Numerous Skin Manifestations
Déficit de vitamina B12 y sus diversas manifestaciones dermatológicas
C. Vera-Kelleta, R. Andino-Navarretea,
Corresponding author
rominaandino@gmail.com

Corresponding author.
, L. Navajas-Galimanyb
a Departamento de Dermatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
b Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
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Two skin biopsies showed a superficial spongiotic and psoriasiform perivascular dermatitis with eosinophils&#44; consistent with an adverse drug reaction&#46; On follow-up at 6 months&#44; the patient presented mucocutaneous jaundice&#44; asthenia&#44; and dyspnea at rest&#46; A series of tests were ordered and the results revealed severe megaloblastic anemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the etiologic study&#44; high titers of antibodies to parietal cells and intrinsic factor were found&#44; and upper digestive tract endoscopy showed chronic atrophic inflammation of the gastric mucosa&#46; The results of the following tests were normal&#58; iron&#44; folate&#44; cortisol&#44; thyroid-stimulating hormone&#44; free thyroxine&#44; rapid plasma reagin&#44; and serological assays for human immunodeficiency virus&#44; hepatitis B virus&#44; and hepatitis C virus&#46; Treatment with intravenous vitamin B12 was started&#46; The patients progressed satisfactorily&#44; with partial regression of the skin lesions and complete remission of hematologic abnormalities after 5 months of follow-up &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Vitamin B12 plays an important role in the synthesis of DNA and RNA&#44; acting as an enzyme cofactor&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Onset of vitamin B12 deficiency is usually subacute&#44; starting when the body&#39;s reserves are exhausted&#46; The deficiency can be caused by a range of nutritional problems&#44; including a lack of intrinsic factor&#44; achlorhydria&#44; ileal disease&#44; malnutrition&#44; and malabsorption syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Diagnosis and treatment are of great clinical importance&#44; mainly because of the progressive hematologic and neurologic involvement&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The following cutaneous manifestations have been described&#58; generalized hyperpigmentation&#44; glossitis&#44; nail abnormalities&#44; and premature graying&#46; Hyperpigmentation is often more pronounced on the limbs&#44; primarily on the dorsum of the hands and feet&#44; in flexural areas&#44; and occasionally on the nails&#44; tongue&#44; and oral mucous membranes&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Since hyperpigmentation is a nonspecific symptom&#44; a broad range of differential diagnoses should be considered in such cases&#58; diabetes mellitus&#44; Addison disease&#44; Cushing syndrome&#44; post-inflammatory lesions&#44; amyloidosis&#44; melanosis of the skin&#44; heavy metal deposition&#44; thyroid disease&#44; tumors&#44; drug reactions&#44; and porphyria cutanea tarda&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The pathophysiology of hyperpigmentation is still a matter of debate&#46; The first hypothesis was proposed by Gilliam and Cox&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> who reported that patients with vitamin B12 deficiency had decreased levels of reduced glutathione &#40;GSH&#41;&#46; It is known that GSH inhibits tyrosinase activity and consequently melanogenesis&#46; Low levels of GSH permit increased tyrosinase activity&#44; and thereby favor an increase in melanogenesis&#46; Griepp<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> proposed a hypothesis involving biopterin&#44; a substance essential to the hydroxylation of phenylalanine&#46; Given the role of phenylalanine in the synthesis of melanin&#44; high levels of this amino acid could explain hyperpigmentation&#46; Marks<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> hypothesized that a change in the location and distribution of melanin might be involved&#44; observing that megaloblastic anemia is associated with a defect in the transport of melanin and its incorporation into keratinocytes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Accurate recognition of the cutaneous manifestations and eventual systemic involvement is essential in establishing a diagnosis&#46; Blood tests may reveal macrocytosis&#44; immature nuclei&#44; and hypersegmented granulocytes&#46; There may be an increase in levels of serum bilirubin and lactate dehydrogenase&#44; as occurred in the present case&#46; The sensitivity of low serum vitamin B12 concentrations &#40;&#60;&#160;200<span class="elsevierStyleHsp" style=""></span>&#40;g&#47;mL&#41; ranges from 65&#37; to 95&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> making it necessary to complement this finding with other tests having greater sensitivity&#46; Levels of methylmalonic acid higher than 400<span class="elsevierStyleHsp" style=""></span>nmol&#47;L and homocysteine above 21<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L have a sensitivity of 98&#37; and 96&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Once the diagnosis is confirmed&#44; the cause of the deficiency should be investigated&#46; In severe cases&#44; it should be remembered that the most common cause of vitamin B12 deficiency is autoimmune gastritis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patient&#44; further tests and explorations revealed high titers of antibodies against parietal cells and intrinsic factor and chronic atrophic inflammation of the gastric mucosa&#46; These findings supported a diagnosis of autoimmune gastritis&#46; However&#44; it should be noted that the patient was receiving treatment with metformin&#44; a drug that has been associated with decreased serum levels of vitamin B12&#46; A recent meta-analysis found treatment with metformin to be significantly associated with an increased incidence of vitamin B12 deficiency and reduced serum levels&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> It is therefore possible that the etiology in this case may have been twofold&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Histology may reveal epidermal thinning&#44; vacuolar changes and nuclear elongation of keratinocytes&#44; increases in the number of melanocytes in basal layers&#44; and the presence of numerous melanophages in the papillary dermis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;9</span></a> Electron microscopy will show intracytoplasmic desmosomes&#44; numerous aggregated bundles of tonofilaments in the cytoplasm of keratinocytes&#44; and highly condensed keratohyalin granules&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In the present case&#44; the results of the 2 histological studies carried out were not consistent with the findings described above and were&#44; rather&#44; indicative of an adverse drug reaction&#46; The possible complementary role in the etiology of 1 of this patient&#39;s medications could explain these findings&#44; and the histological changes associated with the drug reaction may have masked those more often found in cases of vitamin B12 deficiency&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Recommended treatment is based on the administration of vitamin B12 either orally&#44; intravenously&#44; or intramuscularly&#59; a number of management protocols exist&#46; In a randomized clinical trial comparing oral and parenteral therapy&#44; both groups showed similar reductions in mean corpuscular volume and increases in hematocrit at 4 months&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The present case highlights the causal relationship between vitamin B12 deficiency and generalized skin hyperpigmentation&#44; an association that presents a wide variety of dermatological manifestations&#46; Clinical suspicion plays a fundamental role in the diagnostic process&#44; and is higher in patients at higher risk&#44; including vegetarians&#44; malnourished patients&#44; older people&#44; and patients who have malabsorption syndromes or have undergone gastrectomy or bariatric surgery&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Vera-Kellet C&#44; Andino-Navarrete R&#44; Navajas-Galimany L&#46; D&#233;ficit de vitamina B12 y sus diversas manifestaciones dermatol&#243;gicas&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;762&#8211;764&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pretreatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normal Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Erythrocyte count &#40;x10<span class="elsevierStyleSup">6</span>&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0&#8211;5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hemoglobin &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#8211;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hematocrit &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#8211;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mean corpuscular volume &#40;fL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">114&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#8211;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reticulocytes &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&#8211;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Serum B12 levels &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">559&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">200&#8211;900&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anisocytosis&#44; polychromasia&#44; macrocytosis&#44; dacrocyte&#44; hypersegmented neutrophils&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypochromia&#44; polychromasia&#44; microcytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 15782190
Original language: English
DOI:10.1016/j.adengl.2015.09.017
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