Atrophic Glossitis

Generalized muscle weakness, ataxic gait, and numbness and tingling in her hands and feet prompted a 45-year-old woman with a history of heavy alcohol abuse to seek medical attention. Atrophic glossitis (A) and decreased sensation to light, touch, and vibration of the distal extremities were noted.

A peripheral blood smear revealed hypersegmented neutrophils (B and C). Macrocytic anemia and anti-intrinsic factor antibodies were also detected. Although the patient declined further blood testing for a definitive diagnosis, the constellation of findings strongly suggested vitamin B₁₂ deficiency secondary to pernicious (megaloblastic) anemia.

Atrophic glossitis (bald tongue) may be seen in patients with pernicious anemia, iron deficiency anemia, pellagra, and xerostomia. Megaloblastic anemia—anemia with macroovalocytic red blood cells—is rare today because of vitamin supplementation in foods. Although both folic acid and vitamin B₁₂ deficiencies can cause megaloblastic anemia, only B₁₂ deficiency is associated with neurological changes. These changes consist of subacute combined degeneration of the dorsal and lateral spinal columns.

Neurological symptoms of B₁₂ deficiency are usually vague and commonly include ataxia, weakness, loss of vibratory and position sense, and paraplegia (in severe cases). Pancytopenia, macroovalocytes, and hypersegmented neutrophils are the major hematological findings. Hypersegmented neutrophils may also be seen in renal failure and iron deficiency; however, this finding along with macrocytosis is pathognomonic for megaloblastic anemia. Anti-intrinsic factor antibodies are present in the serum of more than 70% of affected patients; thus, this test is highly specific for pernicious anemia.

This patient was treated with intramuscular vitamin B₁₂ injections but was lost to further follow-up.