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      Diagnostic value of oral “beefy red” patch in vitamin B12 deficiency

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          Vitamin B12 deficiency, which may cause serious neuropsychiatric damage, is common in the elderly. The non-specific clinical features of B12 deficiency and unreliable serum parameters make diagnosis difficult. We aimed to evaluate the value of oral “beefy red” patches as a clinical marker of B12 deficiency.


          A diagnostic study was conducted in patients complaining of oral soreness, burning sensation, or severe recurrent oral ulcers. Patients underwent clinical examination and laboratory investigations, including complete blood count and estimation of serum B12, folate, iron, and ferritin levels. Resolution of clinical signs and symptoms after 1 month of B12 supplement was regarded as the diagnostic gold standard.


          Of 136 patients, 70 had B12 deficiency. Among these patients, the oral “beefy red” patch was observed in 61, abnormal mean corpuscular volume (MCV) was noted in 30, and serum cobalamin levels <200 and <350 pg/mL were seen in 59 and 67 cases, respectively. The “beefy red” patch demonstrated the highest diagnostic validity (Youden index 0.84) and reliability (consistency 91.9% [95% CI: 87.3%–96.5%]), followed by the serum cobalamin levels and MCV. The combination of “beefy red” patch with cobalamin <350 pg/mL exhibited better diagnostic value than the combination of “beefy red” patch with cobalamin <200 pg/mL, with accuracy of 0.81 vs 0.74 and reliability of 90.4% (95% CI: 85.5%–95.4%) vs 86.8% (95% CI: 81.1%–92.5%).


          The combination of oral “beefy red” patch and serum cobalamin level <350 pg/mL appears to be useful for diagnosis of B12 deficiency.

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          Most cited references 29

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          Sensitivity of serum methylmalonic acid and total homocysteine determinations for diagnosing cobalamin and folate deficiencies.

          Patients with cobalamin (vitamin B12) deficiency usually lack many of the classic features of severe megaloblastic anemia; because of the low diagnostic specificity of decreased serum cobalamin levels, demonstrating the deficiency unequivocally is often difficult. We examined the sensitivity of measuring serum concentrations of methylmalonic acid and total homocysteine for diagnosing patients with clear-cut cobalamin deficiency and compared the results with those of patients with clear-cut folate deficiency. Serum metabolites were measured for all patients seen from 1982 to 1989 at two university hospitals who met the criteria for cobalamin and folate deficiency states and for such patients seen from 1968 to 1981 from whom stored sera were available. In all, 406 patients had 434 episodes of cobalamin deficiency and 119 patients had 123 episodes of folate deficiency. Criteria for deficiency states included serum vitamin levels, hematologic and neurologic findings, and responses to therapy. Responses were documented in 97% of cobalamin-deficient patients and 76% of folate-deficient patients. Metabolite levels were measured by modified techniques using capillary-gas chromatography and mass spectrometry. Most of the cobalamin-deficient patients had underlying pernicious anemia; two thirds were blacks or Latinos. Hematocrits were normal in 28% and mean cell volumes in 17%. Of the 434 episodes of cobalamin deficiency, 98.4% of serum methylmalonic acid levels and 95.9% of serum homocysteine levels were elevated (greater than 3 standard deviations above the mean in normal subjects). Only one patient had normal levels of both metabolites. Serum homocysteine levels were increased in 91% of the 123 episodes of folate deficiency. Methylmalonic acid was elevated in 12.2% of the folate-deficient patients; in all but one, the elevation was attributable to renal insufficiency or hypovolemia. For the cobalamin-deficient patients, measuring serum metabolite concentrations proved to be a highly sensitive test of deficiency. We conclude that normal levels of both methylmalonic acid and total homocysteine rule out clinically significant cobalamin deficiency with virtual certainty.
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            Vitamin B12 (cobalamin) deficiency in elderly patients.

            Vitamin B12 or cobalamin deficiency occurs frequently (> 20%) among elderly people, but it is often unrecognized because the clinical manifestations are subtle; they are also potentially serious, particularly from a neuropsychiatric and hematological perspective. Causes of the deficiency include, most frequently, food-cobalamin malabsorption syndrome (> 60% of all cases), pernicious anemia (15%-20% of all cases), insufficient dietary intake and malabsorption. Food-cobalamin malabsorption, which has only recently been identified as a significant cause of cobalamin deficiency among elderly people, is characterized by the inability to release cobalamin from food or a deficiency of intestinal cobalamin transport proteins or both. We review the epidemiology and causes of cobalamin deficiency in elderly people, with an emphasis on food-cobalamin malabsorption syndrome. We also review diagnostic and management strategies for cobalamin deficiency.
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              Megaloblastic anemia and other causes of macrocytosis.

               F. Aslinia,  J. Mazza,  S Yale (2006)

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                07 August 2018
                : 14
                : 1391-1397
                [1 ]Department of Oral Medicine, Peking University School and Hospital of Stomatology, Beijing, China, songxiaoliu@ 123456aliyun.com
                [2 ]Discipline of Oral Diagnosis and Polyclinics, Faculty of Dentistry, Prince Philip Dental Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China, lwzheng@ 123456hku.hk
                Author notes
                Correspondence: Xiaosong Liu, Department of Oral Medicine, Peking University School and Hospital of Stomatology, Beijing 100081, China, Tel +86 10 8219 5806, Fax +86 10 8219 3402, Email songxiaoliu@ 123456aliyun.com
                Liwu Zheng, Discipline of Oral Diagnosis and Polyclinics, Faculty of Dentistry, Prince Philip Dental Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China, Tel +852 2859 0558, Fax +852 2858 2532, Email lwzheng@ 123456hku.hk
                © 2018 Zhou et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research


                vitamin b12 deficiency, “beefy red” patch, oral manifestation, diagnosis


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