‘Some days, I would just eat a bag of popcorn’

It looked like just another nonspecific anemia consult this past March. The patient was a 65-year-old woman with a cast on her leg.

“Hello, my name is Dr. Topilow, your doctor asked me to see you for anemia.”

“Why yes, hello, Dr. Topilow,” she exclaimed.

“Do you know me?” I asked.

“Yes, I do. You’re the piano-playing hematologist. I’ve been to your concerts.”

Of course I was flattered but not really surprised. Once I realized that she was the ex-wife of a friend of mine in the community, I got down to business.

The patient had fallen in the supermarket and had sustained an ankle fracture that needed to be surgically fixed. I looked over her lab studies. She had a hemoglobin of 10 on admission, but it had fallen to 7.9 two days later. Her MCV was 111. Her white count and platelet counts were normal on admission.

Arthur Topilow

Two days later she had a WBC of 2.9 and a platelet count of 106,000. Her renal function was rather poor, with an estimated glomerular filtration rate of 28. Her past history included a recent hysterectomy for benign postmenopausal bleeding. She had some delay in wound healing after surgery. It required two months of treatment with V.A.C. Therapy (KCI) for her wound, but when I saw her, she had just about recovered. I had myelodysplastic syndrome on my mind as a possible diagnosis but ordered the usual studies, expecting nonspecific findings.

“I’ll come back tomorrow to review your labs tests,” I said.

A surprise result

The next day I went over her results. To my surprise, her folate level was 2.3 (normal is seven or more). I had obviously missed something in her history.

“Your folic acid level in the blood is very low. Let’s talk about it.”

The patient proceeded to tell me that she had been somewhat depressed over the past year and had lost her appetite. She was a realtor in a high-end neighborhood, and nothing was selling. She had been divorced for the past 12 years after a 25-year marriage and had taken a big loss in her income. During this period, she had lost 150 lb!

I was shocked. Her current weight was 220 lb. She was 5 ft 10 in tall, which was why I hadn’t thought to ask about recent weight loss. The patient admitted to drinking wine only two or three times a week, although I suspected that was an underestimation. A psychiatric consultant said that she had “an adjustment disorder with a depressed and anxious mood.” (No big surprise. Isn’t that the state of the nation today?)

Her past history also included an episode of atrial fibrillation, hypertension and hyperlipidemia. At the time of her recent hysterectomy, she had undergone cardiac catheterization, which showed nonobstructive coronary artery disease and good left ventricular function.

I ordered additional studies, which turned out to be interesting. Her serum albumin was 2.6. Her homocysteine was very high at 55.2 and her methylmalonic acid (MMA) was normal at 0.17 (normal is 0.00 to 0.40). Her B12 level was low normal at 306. Her intrinsic factor antibodies were negative. This constellation of findings (high homocysteine and normal MMA) was quite consistent with folate deficiency (sensitivity of 86% and specificity of 99%). With B12 deficiency, both homocysteine and MMA are elevated.

My concern was the known association between heart failure and elevated levels of homocysteine. The homocysteine level would come down with folic acid treatment, but would it go down to normal? Transfusion could be a potential problem in this patient because of the risk of heart failure with known, but asymptomatic, coronary heart disease. The surgeon was, of course, eager to operate and not willing to wait for her blood and chemistry to recover.

Brushing up

In truth, I had not been knowledgeable about some aspects of folic acid deficiency until I both refreshed and added to my memory the details on UpToDate, the medical computer program, prior to writing my orders. I had used MMA as a marker for B12 deficiency but hadn’t used homocysteine as a marker for folate deficiency. I was unaware of the association between heart failure and elevated homocysteine in adults without prior myocardial infarction. I took a quick survey of my younger associates. They knew about homocysteine in folate deficiency, but were not aware of the association with congestive heart failure.

The patient, in spite of my concerns, was transfused prior to surgery and given folic acid. Fortunately, she sailed through her ankle procedure. Her renal function recovered completely with adequate hydration. Hopefully, she will take her diet and depression problems seriously. I anticipate a rapid recovery. (I wish the same could be said for our country’s economic disaster.)

Arthur Topilow, MD, is in private practice at Atlantic Hematology & Oncology in Manasquan, N.J.

For more information:

• Savage DG. Am J Med. 1994;96: 239-246.
• Vasan RS. JAMA. 2003;289:1251-1257.