HOW TO DIAGNOSE COBALAMIN DEFICIENCY

Cobalamin deficiency must be suspected in all patients with unexplained neuropsychiatric symptoms or unexplained anemia. Special attention should be paid to patients at risk of developing cobalamin deficiency such as elderly people, vegetarians, HIV-infected patients, patients with gastrointestinal diseases and patients with autoimmunity or a family history of pernicious anemia. The assays aimed to answer the question: does this patient suffer from cobalamin deficiency, include analysis of P-cobalamins and analyses of the metabolites that accumulate upon cellular cobalamin deficiency, P-methylmalonate and P-homocysteine. P-cobalamins or especially a fraction of P-cobalamins, P-TC cobalamins are markers for latent cobalamin deficiency. An increased concentration of P-methylmalonate that decreases upon injection of cobalamin indicates overt metabolic cobalamin deficiency. The same holds for P-homocysteine but this analysis is less specific than P-methylmalonate. We suggest that either assay of P-cobalamins or P-methylmalonate is employed as screening test for cobalamin deficiency, and that further tests are performed only if the initial test in combination with the clinical picture gives an unclear answer. Once cobalamin deficiency has been diagnosed, the cause for the deficiency should be sought and the patient should be treated for life. Cobalamin absorption tests such as the Schilling test are considered of limited use. Gastric atrophy is likely to be present in patients with increased P-gastrin or decreased P-pepsinogen A. However, this condition can be diagnosed also by upper gastrointestinal endoscopy.