Rapid Onset of B12 Deficiency in the Setting of Worsening Multiple Myeloma: Correlations between B12 Deficiency and Multiple Myeloma

Abstract

A 67-year-old female with a relapse of multiple myeloma after being in remission for approximately 2 years following autologous stem cell transplant presented with worsening pancytopenia, over a three-month period. There were an increase in her monoclonal spike at 3.13 g/dL on serum protein electrophoresis, low serum B12 levels, and positive intrinsic factor antibodies. Three months before, she had normal B12 levels and a significantly lower monoclonal spike of 1.07 g/dL. She was diagnosed with B12 deficiency with pernicious anaemia in the setting of her worsening myeloma. Multiple myeloma (MM) has been linked with B12 deficiency and pernicious anaemia. Several mechanisms have been described regarding the pathogenesis of B12 deficiency in such patients. Increased tumour activity can further perpetuate the development of B12 deficiency in such patients. With regard to our case, the increase in tumour activity and onset of pernicious anaemia could have contributed to the rapid development of B12 deficiency. In contrast to this, rapid development of B12 deficiency could also signify relapse or worsening of the myeloma as seen in our case. Physicians ought to consider B12 deficiency in patients with worsening pancytopenia and myeloma.

Multiple myeloma with CNS involvement in the form of leptomeningeal carcinomatosis presenting as Vitamin B12 deficiency

“…Multiple myeloma (MM) is a bone marrow-derived clonal plasma cell neoplasm that is characterized by the overproduction of monoclonal antibodies. 3 MM is a devastating disease where patients may develop renal failure, cytopenia, infections because of immunoparesis, electrolyte abnormalities like hypercalcemia, and lytic bone lesions manifesting as skeletal symptoms with back pain and vertebral fractures. 4 Extramedullary dissemination, a rare event, has also been noted with MM and carries a poor prognosis.…”

“… 5 MM involving the CNS is a rare complication of MM occurring in roughly 1% of MM patients with an overall survival of less than 6 months. 5 Based on a review by Dispenzieri and Kyle, intracranial plasmacytomas or myelomas can be classified into four groups: 1 lesions extending from the skull and pressing inward, 2 lesions growing from the dura mater or the leptomeninges, 3 lesions from the mucous membranes of a nasopharyngeal plasmacytoma, and 4 intraparenchymal lesions not arising from any of these other sites. 6 Leptomeningeal involvement is the most common form, often leading to nerve root infiltration and cerebral nerve palsies.…”

“… 7 , 8 Some of the mechanisms of B12 deficiency described are development of specific autoantibodies, possible IgM paraprotein with inherent anti-intrinsic-factor-like activity, or renal dysfunction hindering appropriate B12 absorption. 3 Pernicious anemia has been associated with IgG and IgM kappa type of para-proteinemia along with IgA myeloma. 3 Furthermore, Seegobin et al described worsening of MM in association with B12 deficiency and pernicious anemia.…”

“… 3 Pernicious anemia has been associated with IgG and IgM kappa type of para-proteinemia along with IgA myeloma. 3 Furthermore, Seegobin et al described worsening of MM in association with B12 deficiency and pernicious anemia. They found worsening pancytopenia along with increasing monoclonal paraprotein levels with a simultaneous decrease in B12 levels.…”

“…They found worsening pancytopenia along with increasing monoclonal paraprotein levels with a simultaneous decrease in B12 levels. 3 They concluded that B12 deficiency could possibly behave as a marker of worsening MM and overall disease activity. Yikilmaz et al retrospectively investigated an association between B12 deficiency and MM and concluded that vitamin B12 may carry prognostic significance in disease course.…”