The "Pseudo-TMA" Trap: When High LDH Isn't What You Think

By Dr. Karan R. Rawat

Gastrointestinal Surgeon | Agra

Imagine seeing a blood report with an LDH level of 8000. For context, a normal level is usually under 250.

When we see numbers that high, accompanied by falling hemoglobin and jaundice (bilirubin 2.5), the immediate fear in the medical community is often "TTP" (a rare, deadly blood clotting disorder) or even blood cancer. Patients are often rushed to hematology, terrified, facing treatments as severe as plasma exchange.

But recently, I’ve seen cases where the answer wasn’t in the bone marrow's genetics—it was in the stomach.

The Case: The Numbers That Don't Add Up

A patient presents with extreme fatigue and yellowing eyes. The labs look disastrous:

  • LDH: 8000 IU/L (Massive cell destruction)

  • Hemoglobin: Dropping rapidly

  • Bilirubin: 2.5 mg/dL (Mild jaundice)

  • Coombs Test: Negative (Crucial clue!)

  • Vitamin B12: < 100 pg/mL (Severe deficiency)

The Diagnosis: Pseudo-TMA

This condition is a masquerader. It’s called Megaloblastic Anemia masquerading as Pseudo-TMA.

Here is what is actually happening: The patient has a severe lack of Vitamin B12. The bone marrow is trying desperately to make red blood cells, but without B12, the DNA of these cells cannot mature. The cells are created, but they are defective and fragile. They explode inside the bone marrow before they even reach the bloodstream.

This explosion releases massive amounts of LDH and Bilirubin. To the untrained eye, it looks like the blood is being destroyed by a disease. In reality, the blood is just failing to be born.

The "Negative Coombs Test" is our savior here—it tells us the immune system isn't attacking the blood. The machinery is just out of fuel.

The Gastrointestinal Connection

Why am I, a GI Surgeon, writing about anemia? Because B12 deficiency is almost always a gut issue.

You cannot absorb Vitamin B12 without a healthy stomach and small intestine. Common causes include:

  1. Atrophic Gastritis: The stomach lining thins and stops producing "Intrinsic Factor," a protein needed to grab B12.

  2. Long-term Acid Suppression: Chronic use of antacids can hinder absorption.

  3. Ileal Issues: The terminal ileum (end of the small intestine) is the only place B12 is absorbed. Inflammation or previous surgery here can block it.

  4. Diet: Especially in a city like Agra, strict vegetarian diets without supplementation can lead to dangerously low levels over time.

The "Miracle" Cure

The difference between this diagnosis and TTP is life-saving. We don't need plasma exchange. We don't need chemo.

We need Vitamin B12 injections.

Once we start high-dose parenteral B12, the transformation is dramatic. The reticulocyte count (new blood cells) shoots up in 3-4 days, LDH crashes down, and the patient feels like a new person within a week.

The Takeaway

Never ignore chronic fatigue or mild jaundice. And more importantly, if you see a terrifying lab report, take a breath. Sometimes, the most complex-looking problems have the simplest solutions—rooted right in your nutrition and gut health.

Need a consultation?

Dr. Karan R. Rawat

Gastrointestinal Surgeon

📍 Agra, Uttar Pradesh

(Insert Clinic Address/Contact Info Here)

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