A 46-year-old female patient presented with generalised weakness, weight loss and progressive darkening of the skin on both hands and feet over the previous year. There was no history of fever, altered bowel habits, sensation of tingling or numbness, memory loss, seizure, diabetes mellitus, tuberculosis, abdominal surgery or intake of any regular medication. The patient was a non-smoker, did not drink alcohol and followed a vegetarian diet. The physical examination revealed pallor and hyperpigmentation over palmar and dorsal aspect of hands and feet, with accentuation over terminal phalanges, knuckles, and creases (Figure 1, 2). Other mucocutaneous and systemic examination was non-contributory. Laboratory analysis showed reduced haemoglobin (7.3 gm/dl; reference range 12.1 to 15.1 gm/dl), and vitamin B12 level (69 pg/ml; normal 180-900 pg/ml). Serum cortisol, electrolytes, folic acid, iron, fasting blood sugar, liver, renal and thyroid profile were within normal limits. The upper gastrointestinal endoscopy was unremarkable. Based on the clinical and laboratory findings, a diagnosis of vitamin B12 deficiency was established. The patient was then treated with oral cyanocobalamin 1mg daily for initial two weeks and then weekly. A significant improvement was seen in the first month of treatment.
Figure 1 Addisonian hyperpigmentation over dorsa of the hands and feet, with accentuation over the interphalangeal joints, terminal phalanges
Figure 2 Hyperpigmentation over palms with accentuation over palmer crease
