Vitamin B12 Deficiency
markedly with higher doses.
Definition of terms
1. Megaloblastic anaemia - give rise to characteristic
morphological appearances: the red cells are
macrocytic and hypersegmented neutrophils are
present. Ineffective erythropoiesis is apparent
Structure of Vit B12
1. The vitamin B12 (cobalamin) molecule is centred on
an atom of cobalt; this is the only known function of
cobalt in humans.
2. Vitamin B12 is mainly contained within the
mitochondria in the 5′-deoxyadenosyl form, where
it plays a role in the conversion of l-methylmalonyl-
CoA to succinyl-CoA.
3. The other main form, methylcobalamin, is found
within the cytoplasm and plasma where it is a
cofactor for the conversion of homocysteine to
methionine, a vital part of the pathway that creates a
universal methyl donor
Source of vitamin B12.
1. Vitamin B12 is synthesized only by microorganisms
and the only source for humans is food of animal
origin.
2. Liver is the richest source of vitamin B12, but it is
present in almost all animal products, including
milk.
3. No vegetable food source contains significant
amounts of vitamin B12 unless contaminated by
bacteria
Vitamin B12 requirements.
1. An adult human requires only 1 μg of vitamin B12
per 24 h and has stores of 2–3 mg.
2. Thus, it can take 3–4 years for vitamin B12
deficiency to develop
Absorption of vitamin B12.
1. Dietary vitamin B12 is bound to food proteins and
must be freed by gastric acid. Acid pH and pepsin
release cobalamin.
2. The parietal cells of the stomach secrete the
glycoprotein intrinsic factor (IF), which combines
with vitamin B12 to form a complex, which resists
proteolytic digestion.
3. The vitamin B12–IF complex passes through the
small intestine until it binds to cubilin, a surface
receptor on the enterocytes of the terminal ileum,
where it is internalized.
4. The enterocytes of the ileum have a limited capacity
to absorb vitamin B12 because of a limited number of
receptor sites; about half of a dose of 1 μg of
vitamin B12 will be absorbed, the proportion falling
5. The enterocytes have a refractory period of about 6
h before they can absorb any more vitamin B 12.
6. Within the enterocyte, the vitamin B12 is liberated
and, after binding to the β-globulin carrier
transcobalamin II (TCII), is released into the blood.
7. The TCII–vitamin B12 complex is termed
‘holotranscobalamin’.
8. Transcobalamin II readily releases the vitamin B12 to
the bone marrow and other tissues, and, for this
reason, holotranscobalamin is also described as
‘active B12’.
9. Other transcobalamins also exist; transcobalamin I
and III derive mainly from specific granules found
in neutrophils and bind vitaminB12 tightly, in
contrast to TCII, and do not release it into the
tissues.
10. Congenital TCII deficiency can occur, the affected
infant presenting with megaloblastic anaemia a few
weeks after birth.
Causes of vitamin B12 deficiency
1. Nutritional: this is rare and is only seen in very strict
vegans.
2. Malabsorption: the commonest cause of vitamin
B12 malabsorption is the autoimmune condition,
pernicious anaemia, where gastric atrophy develops
secondary to an inflammatory infiltrate.
Autoantibodies to gastric parietal cells are seen in
90% of individuals with the condition and 50%
develop IF autoantibodies, which either prevent
vitamin B12–IF complex formation (binding
antibodies) or the subsequent attachment of the
vitamin B12 to the enterocyte mucosa (blocking
antibodies).
3. Gastric causes: such as total or partial gastrectomy.
4. Intestinal causes: ileal resection and diseases of the
terminal ileum such as Crohn disease or tropical
sprue prevent vitamin B12 absorption. Deficiency is
also associated with intestinal blind loop syndrome
(because of metabolism of the vitamin B12 by the
overgrowth of intestinal bacteria) and fish tapeworm
(Diphyllobothrium latum), which binds cobalamin,
preventing its absorption.
5. Acquired: prolonged nitrous oxide exposure
oxidizes methylcobalamin to an inactive state and
results in functional vitamin B12 deficiency. This
has been seen in dentists and anaesthetists.
Metformin may be associated with low serum
vitamin B12 concentrations. The exact mechanism
for this is unknown but it has been postulated to be
caused by metformin interfering with the calcium
dependent channels responsible for the ileal
absorption of the vitamin.
Features of vitamin B12 deficiency
Vitamin B12 is a coenzyme in the interconversion of the
different forms of folate so its deficiency results in a
megaloblastic anaemia identical to that seen in folate
deficiency.
Deficiency may also result in neurological symptoms (e.g.
peripheral neuropathy, dysfunction of the posterior columns
of the spinal cord and sometimes psychotic illnesses and
dementia).
The precise mechanism for this has not been elucidated but
may be linked with impaired conversion of homocysteine to
methionine, resulting in either reduced availability of S-
adenosylmethionine impairing sphingomyelin synthesis or in
the toxic accumulation of the homocysteine metabolite S-
adenosylhomocysteine.
Laboratory determination of vitamin B12 status
1. Serum vitamin B12. This is usually measured by
automated immunoassay. Normal concentrations
are 160–1000 ng/L. A low concentration is not
specific for vitamin B12 deficiency and may be found
in one-third of patients with folate deficiency and in
normal pregnancy. Measurement
holotranscobalamin (TCII - bound vitamin B12, or
‘active B12’) may be a more sensitive and specific
indicator of physiologically relevant vitamin B12
deficiency.
2. Serum methylmalonate and homocysteine.
Vitamin B12 deficiency results in the elevation of
methylmalonate and homocysteine concentrations
(see Fig. 27.6). However, concentrations of both
compounds fluctuate and may be raised in renal
impairment, smoking and (on single occasions) in
up to 30% of normal volunteers, making definition
of a specific cut-off level difficult.
3. Deoxyuridine suppression test. The conversion of
deoxyuridine monophosphate (dUMP) to
deoxythymidine monophosphate (dTMP) during
DNA synthesis is by methyl group transfer,
facilitated by both vitamin B12 and folate. The other
source of dTMP is via phosphorylation of
deoxythymidine, catalysed by thymidine kinase,
which is subject to feedback inhibition by its
product, dTMP. Normal marrow, pre-incubated
with dUMP, successfully converts this to dTMP,
and incorporates less subsequently added tritiated
thymidine into DNA. If the marrow is deficient in
either vitamin B12 or folate, methyl group transfer
is reduced, so the cells have greater capacity to
incorporate tritiated thymidine into DNA following
pre-incubation with dUMP.
4. Antibody tests. Tests for the presence of antibodies
to gastric parietal cells are positive in 90% of
patients with pernicious anaemia; however, this test
is not specific as it is also positive in around 15% of
healthy elderly people. The presence of IF
antibodies is more specific but is found in only 50%
of patients with pernicious anaemia.
5.