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Images in Clinical Practices

Indian Pediatrics 2003; 40:170-171

Reversible Cutaneous Hyper-pigmentation in Vitamin B12 Deficiency


A 10-month-old male child presented with irritabilty, pallor, facial puffiness and swelling of feet for 15 days. The child had been exclusively breast fed till three months of age; thereafter he received diluted cow’s milk and occasionally cereals. There was striking hyperpigmentation noticed over knuckles and inter-phalangeal joints of both hands and over dorsa of feet and lateral malleoli (Fig. 1). The nails and mucous membranes were normal. The liver and spleen were palpable 4 cm below the costal margin. The Hb was 5.1 g/dL, and the peripheral blood smear showed macrocytosis, anisocytosis and hyper-segmented neutrophils. Serum LDH was 4645 IU/L (normal range 140-300 IU/L)Serum vitamin B12 level was less than 100pg/mL (normal range: 220-960 pg/mL). The child received 10 mcg of vitamin B12 intra-muscularly daily for one week followed by 100 mcg per week for four weeks. On follow up after four months, the hyperpigmentation over hands and feet had completely disappeared (Fig. 2).

Fig. 1. Hyperpigmentation of skin over the toes and malleoli.

 

Fig. 2. Complete disappearance of hyperpigmentation over hands and feet after four months of vitamin B12 therapy.

Reversible hyperpigmentation of skin has been described as an occasional occurrence in vitamin B12 deficiency. It may be generalized but is most pronounced over inter-phalangeal joints, terminal phalanges, dorsa of the wrists, palmar creases and flexures, and over the face and neck. Irregular pigmentation may also be seen on the extensor aspect of arms and thighs, shins and on the trunk. There may be an associated darkening of the buccal mucosa. The nails and nail beds are usually spared. The hyperpigmentation resembles that seen in Addison’s disease, however no adrenal dys-function has ever been demonstrated in these cases. This hyper-pigmentation has been seen mainly in dark skinned persons and is probably related to chronicity of megalo-blastosis.

Sanjeev R. Ahuja,
Ratna A. Sharma,

Department of Pediatrics,
L.T.M. Medical College & L.T.M. General Hospital,
Sion, Mumbai 400 002.
E-mail: [email protected]

 

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