Pernicious Anemia

By Nancy W. Burkhart, BSDH, EDD

Your patient today is Mary, a 57-year-old African American female. Her chief complaint at the appointment is the red appearance of her tongue. Her family members have commented on the change in color from pink to red, as well as the increased thickness of her tongue (see Figure 1).

Figure 1: Depicting red color of tongue with some fissuring as a result of pernicious anemia. This potpourri of pathologic lesions was created by Dr. J.E. Bouquot, and dedicated to Dr. C.D. Johnson, who collected the cases. Both men are faculty members of the University of Texas Dental Branch at Houston. Photos are derived from patients in the urgent care clinic, of which Dr. Johnson is the long-standing director.

As you begin to review Mary's health history, you note that she is postmenopausal, has some food intolerance such as dairy products, she consumes no over-the-counter medications, and has had surgery three years ago for a hiatal hernia. She also states that she sometimes notices a burning sensation on her tongue with various spicy foods and toothpaste.

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Consider reading these articles by Burkhart

• Leprosy: Hansen's Disease
• Ankyloglossia: Are You Paying Attention?
• Tongue: Granular cell tumor

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You wonder if Mary could have a toothpaste allergy or possibly an allergic response to a food item. A change in toothpaste, the use of a diet diary, and a careful analysis of lifestyle factors led to no tissue improvement within a two-week period. Mary was sent to her physician for a complete blood analysis and a general physical with an assessment of her chief complaints.

After a full assessment with blood analysis, it was determined that Mary is deficient in vitamin B12 and has developed pernicious anemia. It was determined that she is not producing intrinsic factor (IF). She has a very fissured tongue that makes this appearance somewhat unusual with the combination of fissuring and the red color of her tongue. The red appearance is characteristic of a vitamin B12 deficiency.

What is pernicious anemia?

The general term "anemia" may constitute multiple conditions and is not a single disease. The term refers to the blood having an inadequate number of high functioning normal blood cells but the cause may be from different sources. These blood cells are responsible for cycling oxygen and carbon dioxide between the tissues of the body and the lungs. An abnormal number and size of erythrocytes results in fatigue and general weakness.

The terms megaloblastic and macrocytic anemia involve defective deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) resulting in abnormally large erythrocytes with a shortened lifespan. The erythrocytes appear elongated or oval when compared to normal erythrocytes. The two most common reasons that megaloblastic anemia occurs is because of a vitamin B12 (also called cobalamin) deficiency or a folic acid deficiency.

Pernicious anemia is an autoimmune condition in which the body cannot make healthy red blood cells because it does not have enough vitamin B12. Vitamin B12 is found in food, but is not absorbed properly in some individuals. The usual cause is a failure to produce intrinsic factor (IF), a protein that is made in the stomach or produced in the gastric mucosa. The IF is responsible for the transportation of B12 across the intestinal mucosa. In some individuals, an autoimmune response causes a lack of intrinsic factor. There appears to be a genetic propensity linked to the inability of the stomach to produce IF in pernicious anemia. In this case, the immune system makes antibodies or proteins that attack the individual's tissues.

At one time, before B12 treatments were available, the condition was often fatal; however, vitamin B12 is now available in pills and injections. Other causes of a vitamin B12 deficiency include alcoholism, pancreatic disorders, stomach bypass or stapling, gastrointestinal surgery that removes some of the stomach tissue, and even very strict vegetarian diets. Celiac disease, Crohn's disease, and a lack of hydrochloric acid also affect the absorption of vitamin B12. Women are more affected than men, and 1% of the population over 60 years of age is most affected.