[Megaloblastic anemia due to inadequate nutrition]

Over a period of about 6 weeks a 49-year-old woman developed increasing exercise-dependent dyspnoea. Her general practitioner had diagnosed marked megaloblastic anaemia and she was hospitalised for its further elucidation. She reported to have eaten or drunk nothing but sweets, potato chips, salty pretzels, lemonade, coffee and tea over the last 2 years. Alcohol intake had been reliably denied by her and outsiders. On admission she weighed 106 kg, her height was 167 cm, and she looked anaemic, had dyspnoea and a sinus tachycardia. There was no evidence of external or internal bleeding and the physical examination was otherwise unremarkable.

Laboratory tests showed a haemoglobin concentration of 4.7 g/dl, as well as marked folic and vitamin B12 deficiency. The food items taken by her contain practically no cobalamine and no folic acid. Gastroscopy revealed grade 1 reflux oesophagitis. Malabsorption being excluded (normal Schilling test, no demonstrable autoantibodies against parietal cells, no evidence of exocrine pancreatic insufficiency), the lack of both vitamins and the megaloblastic anaemia caused by it could be explained only by a deficient food intake over several years.

After administration of cobalamine (1 mg intramuscularly twice weekly for 6 weeks, then 300 micrograms daily by mouth for 4 weeks) and folic acid (5 mg twice daily for 10 weeks), as well as a well-balanced diet as prescribed by a dietician, reticulocyte and erythrocyte concentrations had quickly risen to normal at a follow-up examination 2 months later.

The case of an anaemia entirely caused by a deficient diet dearly illustrates the need of a well-balanced food intake even in adults.