This male patient was referred to a local internist with hematological profile. His urologist asked whether the involuntary childlessness of the patient was due to a value of his S-cobalamins close to the lower reference range.
The patient was a male born 1960. His mother and grandmother suffered from insulin-dependent diabetes mellitus. His grandmother was also treated with oral raw liver preparations and parenteral iron for anemia some decades ago.
The patient worked as an odd-job man and an artist. He smoked 15-20 cigarettes a day, used some spirits, and had tried smoking cannabis in his teens. About 1980, he was examined for epilepsy of unknown origin, brain CT normal. He was treated with carbamazepine for two years. Later he contracted typhoidosis, salmonellosis and shigellosis in Indonesia without sequelae after recovery.
About 1990, the patient lived with a woman according to the law of Mose. Their union was, however, not blessed with any child. The wife was acquitted in a "complete" infertility investigation. The patient was accused of their infertility due to "few and weak" sperms. The urologist pondered whether their infertility was due to a value (156 pmol/L) of the serum cobalamins of the patient in the low range of the reference interval, 130-650 pmol/L.
The patient arrived to the internist about 1991. He reported episodic parestesias in both arms and a slightly sore tongue. These symptoms could not be verified by objective observations. His S-cobalamins had decreased to 88 pmol/L, his B-hemoglobin to 115 g/L. His red cells were large , with a mean cell volume of 119 (ref.82-102) fL.
Behind the abnormalities in the blood picture of the patient was a "severe antrum-sparing atrophic gastritis" at gastroscopy. The atrophic gastritis was verified by high serum levels of gastrin and low levels of pepsinogen I.
The patient was treated with parenteral vitamin B12. His wife conceived during her first ovulation after start of B12 therapy and gave birth to a healthy child in due time. The patient reorganized his lifte style and continued on B12 supplementation. "Parents do not rear children. Children do rear their parents".
The internist understood that he had encountered a classical case of vitamin B12 deficiency with involuntary infertility as first sign. In the past, the likely diagnosis would be "asymptomatic pernicious anemia with probable autoimmune etiology and hereditary predisposition". In the future, the internist is planning to discuss with his colleges in primary health care, whether man and woman should try for example oral cyanocobalamin 1 mg and oral folic acid 5mg daily for a year, before they are sent to an infertility investigation.
The message of this case report is the role of the hereditary predisposition for autoimmune atrophic gastritis. The condition is nowadays easy to demonstrate. The secondary vitamin deficiencies are not restricted to symptomatic anemia and neuropathy.
Updated januari 06, 2000