Images in Clinical Medicine

Vitiligo and Pernicious Anemia

Fritz Egli, M.D., and Roland Walter, M.D.

N Engl J Med 2004; 350:2698June 24, 2004

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Article

A 45-year-old woman with a 17-year history of vitiligo (panel A) was evaluated because of persistent fatigue. She was found to have pancytopenia (white-cell count, 3200 per cubic millimeter; hemoglobin level, 8.1 g per deciliter; and platelet count, 147,000 per cubic millimeter) with macrocytosis (mean corpuscular volume, 125 μm³) and hypersegmented polymorphonuclear leukocytes (Panel B; hematoxylin and eosin, ×100). The serum vitamin B₁₂ level was 84 pmol per liter (normal range, 220 to 660). The serum folate level was normal. Erythroid hyperplasia with left-shifted megaloblastic erythropoiesis and giant metamyelocytes (Panel C, arrow; hematoxylin and eosin, ×100) was seen in the marrow aspirate. Gastric biopsy (specimen not shown) revealed severe alterations of the mucosa with glandular atrophy and intestinal metaplasia. The diagnosis of chronic atrophic gastritis type A (autoimmune) was supported by the finding of markedly elevated serum levels of antibodies to gastric parietal cells (1:260; normal value, <1:10). The patient was treated with intramuscular vitamin B₁₂, and the hematologic abnormalities completely resolved.

Increasing evidence suggests that vitiligo is an autoimmune disorder. It may be associated with other autoimmune diseases, such as pernicious anemia, rheumatoid arthritis, type 1 diabetes, alopecia areata, and diseases of the thyroid gland, or it may be a manifestation of a polyglandular autoimmune syndrome.

Fritz Egli, M.D.
Roland Walter, M.D.
Kantonsspital, CH-7000 Chur, Switzerland