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).
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|
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]
