Oral Manifestations of Vitamin B12 Deficiency
A 41-year-old woman reported with a chief complaint was difficulty in eating certain types of food (mainly banana and tomato) because of a burning sensation and the presence of red stains on the inside of her cheeks and on her tongue.

She had been a strict vegetarian for 2.5 years and had not consumed milk, cheese, fish, meat or eggs during that time. She was not taking any medication. The current symptoms had been present for more than a year. During clinical evaluation, paleness and dry lips were detected. The patient also displayed a disturbance of taste (she was unable to sense the flavour of a variety of fruits and vegetables), fatigue after simple daily activities, paresthesia of the anatomic structures innervated by the mandibular division of the trigeminal nerve on her left side, disturbance of memory and slowing mental faculty, characterized by forgetting recent facts, dates, appointments and difficulty in answering simple questions, respectively.

Oral examination revealed pale oral mucosa, glossitis with papillary atrophy and multiple areas of painful erythema on the dorsal surface and lateral borders of the tongue and buccal mucosa. The mucosa covering the lesions appeared atrophic, but no frank ulceration was evident. Hematologic tests were done. Neutrophil nuclei were hypersegmented, with more than 5 lobes. Anti-intrinsic factor antibodies were not detected, therefore it was not necessary to perform the Schilling test.

A diagnosis of megaloblastic anemia was made based on the high levels of mean corpuscule volume and red cell distribution width, neutrophil hypersegmentation and cobalamin deficiency, and the patient was referred to a centre for hemotherapy and hematology. Treatment comprised parenteral doses of cobalamin (1,000 mg/week hydroxocobalamin administered intramuscularly over 30 days) and 1 mg of folic acid daily for 30 days.

Blood cell counts were repeated monthly. The patient was asked to modify her diet and to add beef liver daily. She returned weekly to the surgery and buccal pathology service for evaluation of her oral lesions, which began to diminish during the first week of therapy. After 14 days of treatment, the lesions had completely disappeared, as had all other symptoms.

Source: http://www.cda-adc.ca/jcda/vol-75/issue-7/533.pdf
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