A Case Report of Combined Severe Vitamin B12, Folate and Iron Deficiency Anaemia in a 44-Year-Old Lady:  Unusual Presentations with Haemolysis, Microcytosis and Pancytopenia

A 44-year-old female with history of inadequate consumption of food of animal origin, presented with worsening symptoms of anaemia with a past medical history of passing dark tarry stools, heavy menses and multiple blood transfusions during her pregnancies. She is a nonsmoker, does not consume alcohol, no illicit drug use. Physical examination revealed jaundice, petechiae & ecchymoses and pallor without organomegaly or lymphadenopathy. Her initial haemoglobin was 2.1 g/dL with a mean corpuscular volume of 57.3 fL, an elevated red blood cell distribution width of 27.5%, platelet count of 25.2 × 103/µL and total WBC 2.7 × 103/µL. Peripheral blood smear revealed pancytopenia with anisocytosis, poikilocytosis, microcytosis, occasional large cells, elliptocytes, fragments and absence of hyper segmented neutrophils. Her liver & renal function tests were normal except for elevated total bilirubin of 42.5 µmol/L. Further investigations revealed elevated serum lactate dehydrogenase (LDH) of 467 U/L, serum ferritin 1787.7, elevated C-Reactive Protein (CRP), very low serum folate of 0.7 ng/ml & serum vitamin B12 <83 pg/ml, negative H. Pylori stool antigen occult blood, negative coombs test (both direct and indirect). The patient was diagnosed with haemolytic anaemia secondary to vitamin B12 deficiency, with concomitant folate and iron deficiency anaemia based on morphology.