Megaloblastic anaemia in psychogenic eating disorders

History and admission findings:A 68-year-old woman had progressively lost s trength over the past 5 years and become bed-ridden. She reported gradually reducing her diet during the last few years, for the last two years restri cting herself to oatmeal, biscuits and water. Acute exacerbation of dyspnoe a, dizziness, tachycardia and cardiac arrhythmias for the last 3 month nece ssitated her emergency admission when she was found to have oedema of the l imbs and definite jaundice, as well as predominantly distal sensory deficit s in the legs, a slightly ataxic gait and poor reflexes in the limbs. Investigations: She was found to have pancytopenia with marked megaloblasti c anaemia (haemoglobin 4.8 mg/dl, mean red cell volume 147.8 fl, leucocytop enia 41/nl), marked haemolysis (lactate dehydrogenase 1629 U/I, haptohaemog lobin < 0.1 g/l, total bilirubin concentration 4.5 mg/dl). Pernicious anaem ia was excluded: no antibodies against parietal cells and intrinsic factor, and no atrophic gastritis in a gastric biopsy. Diagnosis, treatment and course: Megaloblastic anaemia due to dietary defic iencies with early funicular myelosis was suspected. After infusion of four erythrocyte concentrates and Vitamin B-12 administration the symptoms and blood picture improved within days. Conclusion: Although dietary causes of megaloblastic anaemia are rare in Ce ntral Europe, they must be considered in the differential diagnosis, especi ally in the elderly and those with psychogenic disorders.