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Cough mixture abuse as a novel cause of megaloblastic anaemia and peripheral neuropathy

Cough mixture abuse as a novel cause of megaloblastic anaemia and peripheral neuropathy

  1. trptamene
    We report four young Chinese men with reversible peripheral
    neuropathy and macrocytic anaemia caused by severe folate
    deficiency secondary to cough mixture abuse. Their clinical
    and laboratory details are shown in Table I. All patients had
    severe dental carries caused by the high syrup content of
    cough mixture. They were chronic smokers but only social
    drinkers, and denied intravenous or inhalational use of
    narcotics. Blood tests showed negative human immunodeficiency
    virus serology, normal albumin level and liver/renal
    function and negative screening for heavy metal poisoning.
    Toxicology screening detected various combinations of codeine, pseudoephedrine, promethazine, phenothiazine,
    dextromethorphan, benzodiazepam, caffeine and chlorpheniramine.
    Neurological examination showed grade 4+ limb
    weakness, severe glove and stocking anaesthesia, postural
    hypotension and absent reflexes. Peripheral blood examination
    showed anisocytosis, macro-ovalocytes and neutrophil
    hypersegmentation. Both vitamin B12 and folate levels
    (Access system; Beckman Coulter, FL, USA) were low, but
    more severely so, for the latter (Table I). Homocysteine and
    methylmalonic acid (MMA) levels were assayed on fresh sera
    in two cases, using gas chromatography-mass spectroscopy with isotope dilution, and fluorescence polarization immunoassay
    (Abbott IMx system; Abbott Park, IL, USA), respectively.
    The results confirmed severe folate deficiency and
    secondary low vitamin B12 levels (Table I). Bone marrow
    biopsies in cases 1 and 2 showed megaloblastic changes. Antiparietal
    cell and intrinsic factor antibodies were uniformly
    negative, while upper endoscopy in cases 1–3 showed
    no atrophic gastritis. However, Schilling’s test was unavailable
    locally. Electrophysiological studies showed axonal
    degeneration with minimal demyelination changes. Sural
    nerve biopsies in cases 3 and 4 showed a severe reduction in
    the number of myelinated fibres, with ongoing active
    degeneration and near absent large fibres. The patients were
    treated with oral multivitamin and folate (10 g/d) and
    intramuscular injection of vitamin B12 (1 mg, thrice a
    week), with complete neurological recovery and normalization
    of haemoglobin, mean corpuscular volume and vitamin
    B12 and folate levels at 3 months.

    Au et al. Cough mixture abuse as a novel cause of megaloblastic anaemia and peripheral neuropathy. Br J Haematol 2003 Dec;123(5):956-8.