outa deficiency of vitamin 8-12 has been reported, yet -sipeople ingesting vitamin 81 2:deficient diets even for ‘imyyears appear to achieve a balance that does not lead to signs and symptoms of deficiency. | present ine case of ‘nepanof 25 years’ duration who developed severe “alti abnormalities due to vitamin-B12 deticiency. His Set provided 1.2 ug ot vitamin B12 daily at most. Despite “mal Shing test findings, he absorbed subncormal ‘ints of vitamin B12 given with ovalbumin. Ths poor ‘Santon appeared tobe related to his gastritis, rhyria, and subnormat intrinsic actor secretion. ‘ota vitamin-B12 deficiency inthis patient resulted from ‘an tar restriction and the subtle malabsorption, neither ‘tach would have sufficed alone to produce the cliical ‘elem, Possibly such malabsorption may also be present in ‘ayof tose yegans developing overt vitamin'B12 ‘#siency in whom Schilling test findings have been normal Ti vatues for body stores and the daily requirement “Tvtain BLD are puted. but the former pears 10 sed the ater by about 1000 tines (1) Tis sas ws sems to explain the rarity of clinical vitamin-BI2 see cated by dctary inutiieny. [A vegan det vou nt only of meat but sn of aad products “hs cues and dairy products—would have to be strict: foe or many years to deplete body stores of vit atin Scrum vitanin-B12 levels often fall to low levels in 9 ur the st 2 to 3 years OGictary restition ‘ange little thereafter @) and erythrocyte ic sels appear tobe no different fom those i “Aceording to most Surveys, SENS ‘STomamin-BLg deficiency fail to develop 2 1 of vegans (Thus those few who do kp wii abnormal possibly have dietary in- “std,” pleted by coextting orders. The need Sara ude coensting absorptive abnormalities Me actyspg purely dietary explanation has been tated out Gea Further, detection of subtle malab- “Ption may require more sensitive testing methods than amecly goed. hogs Co a a sel ce ee Nutritional Vitamin-B12 Deficiency Possible Contributory Role of Subtle Vitamin-B12 Malabsorption RALPH CARMEL, MO; Los Angeles. California Case Report TA 87-year-old white man eapericncet ileal in walking foe stsnat monte sad see adnate to hospital sa May 1976, He iad ce goat ealsh nil 1972, when easy fatiguing Te 0 hhicsemetsennnt. Hi had abstained fron ll meat sh coffee fad ate! forte last 28 yeare st had vcd eggs and most, thaty preints His family hisors included maternal diabetes this dict hut, unbKe him, took vitaniin supplements and were ii [it he noted weight loss, Weakness, loss of balance, pos tional digsiness gd ake adem. A chiropractic “nutritionist Visited @ aay font and rk regimen of carr joie and “ctclly digcoumed sian B12 when dhe patent inquired Ghout prssible defisencs, Whatever dairy produce the patient Miah cating: was eiscontimucl a replaced By a. ok Maik every other day, The patient has alse consumed 0.810 1K Sftearnats in juice daily since then, He improved transiently but Wa lovs developed a hroad-hascl gat, numbaess and tingling i His hands and fet. less af pstinal sense and dysesthesia be The the knees Two wosks Before admission he began taking 100 fice itamin BI? orally every day, a8 well 36 micin. om, and Stam "Abnormal piysical findings were fimited to orange-yelion skin without scleral eters browd:haved gait absent brat Jy_ponitonal touch and pinprick sensation below the knees and REIN thse sensory etattics in fh hands: dysesthesia of thecaves, and ald pedal eters, Hie weight was $8 kg and his. Height, 172 cm. Abnormal laboratory data included a hemo bilevel of 13-1 p/h mean corpuscular volume 109 f minimal FPERIaY Bhette dehydrogenase level. and hyperearoteneria Scrum sitaqun BI evel wan 146 g/ire (normal, 150 v0 90. Sohal atc aid level serum vitanin BI2-binging proteins, and [atric nd smull-bowel rocntgenogram findings were normal. “{fSccment with dolly 1000 gf vtarsie-BL2 ection for 3 wetks produced rapa! hematologic and gradual neurologie i Pentcafene: Carotencmia improved: when carro intake a Flapped. Monthly injections of sitasia B12 were continued for comes at whieh time oral therapy wit 100 wp daily as Subsrtuted. By then, the ualy neurologic deft was in Wt feet "The patient has aliered his diet to tnelude tuna fish, mith ‘iced corealt and eggs but continues 0 abstain from meat. He fins maintained is serum vitamin-B12 level at about 300 ng ‘Gauci juice was aspired for 1 befoee and alter etazole ssintulation after measurement of pH. he juice was depen EG by atkaliieaton to pH 10 for 20 minutes, neutralized to Bata and assayed for intrnsic factor activity (6), {rhelhatent collected the maximom amount of food he would cat in day This diet, consumed until 1974, contained washed Fast Cuhnce bananas, two apples, one fear), washed vegetables CE etice”eatbage, kebabs, tomato, beet. turnip. green (21978 anrcan sive st Physeans GATCae ee eg {able 1. Vitamin B12 Absorption and Gastric Function Stuies* June Ostober January Wie W916 TT Shing es, 9 a0 iia) GralbugainesCo AID atworpion test, 126 Gast eeton Vole 1s no pH a “3s Inirimic factor content, me aniti 6812 Serum pete ne 630 ‘Serum antibody “Antipas cll + Anicinrins: factor pepper, cucumber), eashews and ether nuts, one cal of Cain Fen vegetarian vegetable soup (Campbell Soup Co, Camden, New Jersey), one container of imation van ie cream, one processed American cheese sandwich on Fye toast, and one Pea Fur butter and jelly sandwich on rye toast. Three hundred mil litres of carrot juice wth pulp and a raw egg yolk were collected separately. These diets were then homogenized with stile, ‘deonized water in a Waring blender (Waring Products, New Hanford, Connecticut) Aliquots were acidified and reated tvith pepuin for 30 minutes reneutralized, nd autoclaved. The Tguid srs extracted by centrifugation and assayed for vitamin {812 content (7. ‘Vitamin-B12 absorption was tested by the standard urinaty excretion method. wing Dé pg of "Co-ibeied eyanocobalamin (Co BI). In adition, 10 days hefore the Sciling test in Jan fuary 1977 an ovalbumin. °Co BY? absoention test (8) was done, ‘sing material provided by De. Alfred Doscherholmen (Veter Sans Adminstration Hospital, Minneapolis, Minnesota) and fo lowing his protocol exactly. ‘The fasting patient was given 06 ig of Co B12 (045 uC in $0 ¢ of ovalbumin, which was heated ina microwave oven and immediately served with lack Coffe: and toast. Sit houts liter nonradioactive wwtamin B12 {1000 jg) wae injected ands 24h urine collection begun. Ra Sicaerivity inthe urine way compared with that in 3 pete Of ‘valoumin-"Co B12 digested with ICI and pepsin Results ‘The results of the patient's vitamin-B12 absorption and gastric studies are shown in Table I. The ovaloumnin-"Co B12 absorption test was subnormal 7 months after inten sive vitamin-B12 therapy, and gastric analysis eemained ‘essentially unchanged afer 4 months of such therapy The patient's pre-I974 diet was found to contain 12 ‘ng of vitamin BIZ. The value represents his maximal vi tamin B12 intake, since on many days he did not eat the dairy products that probably provided most of his vita min, These dairy products along with the peanut butter sandwich were removed from his diet in 1973, The carrot juice and egg yolk, taken every other day after 1974, con tained 0.3 jg of vitamin B12 Discussion Several authors (4, 5) have pointed out that un: ‘equivocal proof of megaloblastic anemia arising from un: ‘complicated dietary deficiency of vitamin BI2 has rarely been presented. The fact that overt manifestations of dei- ciency are the exception rather than the rule, even in GAB Mey 1978» Aone otnteritaccine # Youn 89° Number set vgan, partly spore sch sei late deficiency is not responsible for megalosiaant™ that vitamin B12 is absorbed normally, These nao'® ve been met n-some reports Sty trim) mom hae MaeglcGt prot of teary dec satan of eopone oa sal anal do? Those noteworthy that one vegans Iiuk therapy deopte «normal tear thes eponed pent rexponde ome although one of them @ espe Coe armtker juerum he ea Pawan hemaolope esponse Wasa Theretre, my pin» of some ne sonia paces cause aha ala ses of amin BI. Mt rove steerer! nea vtamin bid 1 been able to absorb most of it, he rigit havea Peatscsexcugh to ails low bose fore in men veeans Who appa to ution ene carne inthe raced ease es However, my patients dctaryinvucteny worse vated by subtle abnormalities in his vitamin-Bia wet BP usicnee tive process, with achlorhydria and decreased suanes 8 )aswoae® trinsiesfactor secretion. The incidental notation of g1. Sisal atrophy in several vegans with clinical vitamin Bit ay f+ cage! ciency (O_1 may thus be relevant, Although te mabe trie lesions were speculated to have resulted from { vitamin-B12 deficiency. and secondary gare wj.s 3 iment may occur in other situations (17 no prea ‘ was offered. In my patient, gastric faction emainas 4 1c i cece preliminary report (3B) sings mote Sat eytem supports their fining Neverthe. these methods the cyanocobaamin sed m3 physolope. Stewart, Roberts, and Hoffrand (3 Pennted out the seeming paradox of hema ° ovement afer 1 og of or eyanocobalamin 8 tho had Become vitamin-BI2 depleted while st testing about that same aouat i ood Probably, my patients poor dietary intake B12 over many ara resulted in m prea symptomatic, vtami-B12 balance. When B'% Phy and suboptimal intrinsic factor sesreton ie $b fod vitamin B12 malabsorption follows. the balance. Perhaps compromised reabsortin 2 vitamin BID also contributed; no ets mew process ure currently availabe. These even Poweseded his dietary change in 1974, since symptoms pre fed that dietary change. ‘Thus vitamin-BI2 absorption should be tested even: shen dietary intake of vitamin appears abnormal. Fur- ier testing with crystalline vitamin B12 may occasional- iy be misleading, Tests such as the ovalbumin test of Dos sholmen, MeMahon, and Ripley (8), although i ‘archanism is unknown, may prove mote physiologic. \ckNOWLEDOMENTS. The author thinks Dr. Aira Doscherlen ‘eg smn ad he ta ean Ga Sabvng serum eas ively nd ty Bar for techs ihr Caor Sebo of Meine 2028 Zonal Ave: Los AN feierences eri nan The nln ef amin BL2 fom nal foods by neces Sart ABM Vian B12 and vegetarians, in Vian 2 ie ovine Fatt 2 Europes Sympeion Habre at 8 ons ns thee oi she whe aia BI ber E28 Chin Med 46; EET at RE Nac in 2 ees. Mad w niin cpa wih una amin BLD detec et Sint Gr ieensen He * 1 Anna, Casa roa Bencrranoisise A, SWAIN WR: Epa assimilation of ems Co" Televi: Gaurerteaigy 4915913, 973 20 EEE tinh: Towns P. Pos. pound wari B12 mab LORE