A Case Report of Combined Severe Vitamin B12, Folate and Iron Deficiency Anaemia in a 44-Year-Old Lady: Unusual Presentations with Haemolysis, Microcytosis and Pancytopenia

A 44-year-old female with history of inadequate consumption of food of animal origin, presented with worsening symptoms of anaemia with a past medical history of passing dark tarry stools, heavy menses and multiple blood transfusions during her pregnancies. She is a nonsmoker, does not consume alcohol, no illicit drug use. Physical examination revealed jaundice, petechiae & ecchymoses and pallor without organomegaly or lymphadenopathy. Her initial haemoglobin was 2.1 g/dL with a mean corpuscular volume of 57.3 fL, an elevated red blood cell distribution width of 27.5%, platelet count of 25.2 × 103/µL and total WBC 2.7 × 103/µL. Peripheral blood smear revealed pancytopenia with anisocytosis, poikilocytosis, microcytosis, occasional large cells, elliptocytes, fragments and absence of hyper segmented neutrophils. Her liver & renal function tests were normal except for elevated total bilirubin of 42.5 µmol/L. Further investigations revealed elevated serum lactate dehydrogenase (LDH) of 467 U/L, serum ferritin 1787.7, elevated C-Reactive Protein (CRP), very low serum folate of 0.7 ng/ml & serum vitamin B12