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  Table of Contents  
LETTER TO THE EDITOR
Year : 2016  |  Volume : 7  |  Issue : 3  |  Page : 215-217  

Reticulate pigmentation associated with vitamin B12deficiency


1 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2 Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Web Publication13-May-2016

Correspondence Address:
Dipankar De
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.182350

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How to cite this article:
Arora Ak, Saini SS, De D, Handa S. Reticulate pigmentation associated with vitamin B12deficiency. Indian Dermatol Online J 2016;7:215-7

How to cite this URL:
Arora Ak, Saini SS, De D, Handa S. Reticulate pigmentation associated with vitamin B12deficiency. Indian Dermatol Online J [serial online] 2016 [cited 2019 Oct 14];7:215-7. Available from: http://www.idoj.in/text.asp?2016/7/3/215/182350

Sir,

Vitamin B12 deficiency is common in India, as a majority of the population is vegetarian.[1] Infants of vitamin B12 deficient mothers are likely to be deficient and they can display various systemic manifestations of vitamin B12 deficiency. Alterations in skin pigmentation has been described as a clinical manifestation of B12 deficiency.[2] We present a case of a 5-month-old infant who presented with an unusual pattern of cutaneous pigmentation on the extremities associated with vitamin B12 deficiency.

A 5-month-old-infant was brought to us with reticulate hyperpigmentation of upper and lower limbs of one month duration. Hyperpigmentation started on the lower limbs [Figure 1] and slowly progressed to affect the upper limbs. It was an asymptomatic brownish reticulate pigmentation pattern resembling livedo reticularis. His mother was from a low socioeconomic background and the child was exclusively breastfed. The mother was a pure vegetarian who did not take vitamin B12 supplement during pregnancy or lactation. His weight was 4.7 kg (50th centile) and head circumference was 39 cm (<3rd centile). The baby had severe pallor. Systemic examination was unremarkable. He had delay in achieving gross motor and personosocial milestones. On laboratory examination, he had anemia (hemoglobin 5.8 g/dL) and thrombocytopenia (platelet count 61 × 103/mm 3). The total leukocyte count (TLC) was normal 8.2 × 103/mm 3 (6-17.5 × 103/mm 3). His hematological indices—mean corpuscular volume (MCV) 101 fL (70–86 fL), mean corpuscular hemoglobin 38.8 pg (25–35 pg), mean corpuscular hemoglobin concentration (MCHC) 39.2% (30%–36%)—suggested macrocytic anemia. Vitamin B12 deficiency was suspected on clinical grounds and hematological data. Blood sample for serum vitamin B12 was sent. Unfortunately, the sample got hemolysed and as vitamin B12 supplementation had already been started, a repeat sample could not be sent. The patient was given a single intramuscular injection of 500 µg of vitamin B12 along with daily supplementation of 5 µg of vitamin B12, folic acid 0.5 mg, and ferrous fumarate 100 mg as a syrup formulation (syrup Vitcofol ®). At one month followup, cutaneous hyperpigmentation disappeared completely [Figure 2]. His general wellbeing improved. He was playful and had started catching up on his motor milestones. His hematological indices normalized one month after treatment (hemoglobin: 12.2 g/dL; MCV 80.5; MCH 26 pg; MCHC 32.5%; TLC 9000/mm 3, and platelet count 188 × 103/mm 3). The patient was continued on daily supplementation of vitamin B12 for 3 months and advised dietary management. Although vitamin B12 levels were not available in this case, circumstantial evidence, based on improvement in hematological picture and disappearance of cutaneous pigmentation after 1 month of vitamin B12 supplementation, strongly suggests that the cutaneous hyperpigmentation was due to vitamin B12 deficiency.
Figure 1: Reticulate hyperpigmentation on lower limb

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Figure 2: Complete disappearance of pigmentation after one month of treatment

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Dietary B12 is obtained mainly from foods of animal origin. Hence childhood vitamin B12 deficiency is common in some parts of India where people follow strict vegetarian diet. Exclusively breastfed infants of vegetarian mothers are at a higher risk.[3] Dermatological manifestations of B12 deficiency include cutaneous and mucosal hyperpigmentation.[4] The pigmentary changes have been described as deep brown or brownish-black hyperpigmentation predominantly affecting hands and feet (especially the knuckles, periungum, and palmar creases) and oral mucosa.[4] Occasionally, hyperpigmentation is accentuated on the pressure points such as elbows, malleoli, and knees.[5] Nail changes and premature graying have also been reported.[5] The cutaneous hyperpigmentation in our child was present in a reticulate pattern along with typical hematological manifestations of vitamin B12 deficiency. Furthermore, the dermatological and hematological manifestations improved after vitamin B12 supplementation. Such a pattern of pigmentation with vitamin B12 deficiency has not been described earlier. Extracutaneous manifestations of vitamin B12 deficiency include megaloblastic anemia and an array of neurologic changes, from personality alteration and poor school performance to hypotonia, ataxia, or seizures.[6] Our patient had delay in achieving milestones at presentation. He quickly started catching up on milestones after vitamin B12 supplementation.

Various mechanisms have been suggested to explain hyperpigmentation associated with vitamin B12 deficiency. According to one hypothesis, the deficiency of vitamin B12 decreases glutathione levels which in turn activates tyrosinase and leads to increased melanogenesis.[7] In another hypothesis, hyperpigmentation has been attributed to a defect in the melanin transfer between melanocytes and keratinocytes, resulting in pigmentary incontinence.[8] Appropriate treatment results in dramatic clinical and laboratory response in most patients, particularly, in hematologic and cutaneous changes.[3] However, neurologic damage may persist.[9] The long-term prognosis of B12 deficiency is related to the severity and duration of deficiency, underlining the importance of early diagnosis and treatment based on cutaneous findings.

The National Anaemia Prophylaxis Programme in India mandates folic acid and iron (0.5 mg and 100 mg, respectively) supplementation.[10] However, vitamin B12 supplementation for young girls and pregnant women has not been recommended. These guidelines are derived from western data where majority of population is nonvegetarian unlike most Indian women. Since many of the serious consequences of B12 deficiency could be prevented through proper supplementation, it seems reasonable to recommend that women take supplemental B12 while they are pregnant or breastfeeding, especially if they are vegetarian. This case highlights the need to review current practices of vitamin supplementation among pregnant Indian women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Antony AC. Prevalence of cobalamin (vitamin B-12) and folate deficiency in India: Audi alteram partem. Am J Clin Nutr 2001;74:157-9.  Back to cited text no. 1
    
2.
Jadhav M, Webb JK, Vaishnava S, Baker SJ. Vitamin B12 deficiency in Indian infants. A clinical syndrome. Lancet 1962;2:903-7.  Back to cited text no. 2
    
3.
Weiss R, Fogelman Y, Bennett M. Severe vitamin B12 deficiency in an infant associated with a maternal deficiency and a strict vegetarian diet. J Pediatr Hematol Oncol 2004;26:270-1.  Back to cited text no. 3
    
4.
Baker SJ, Ignatius M, Johnson S, Vaish SK. Hyperpigmentation of skin. Br Med J 1963;1:1713-5.  Back to cited text no. 4
    
5.
Noppakun N, Swasdikul D. Reversible hyperpigmentation of skin and nails with white hair due to vitamin B12 deficiency. Arch Dermatol 1986;122:896-9.  Back to cited text no. 5
    
6.
Heath ML, Sidbury R. Cutaneous manifestations of nutritional deficiency. Curr Opin Pediatr 2006;18:417-22.  Back to cited text no. 6
    
7.
Gilliam JN, Cox AJ. Epidermal changes in vitamin B12 deficiency. Arch Dermatol 1973;107:231-6.  Back to cited text no. 7
    
8.
Marks VJ, Briggaman RA, Wheeler CE Jr, Hyperpigmentation in megaloblastic anemia. J Am Acad Dermatol 1985;12:914-7.  Back to cited text no. 8
    
9.
Graham SM, Arvela OM, Wise GA. Long-term neurological consequences of nutritional vitamin B12 deficiency in infants. J Pediatr 1992;121:710-4.  Back to cited text no. 9
    
10.
National Nutrition Anemia Prophylaxis Programme. National Institute of Health and Family Welfare. 2003. Available from: target="_blank" href="http://nihfw.nic.in/ndc-nihfw/html/Programmes/NationalNutritionAnemia.htm". [Last accessed on 2014 Oct 29].  Back to cited text no. 10
    


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