Pernicious anemia is associated with a subacute degeneration of the brain that is essentially the same as the more familiar subacute degeneration of the spinal cord. The pathological process is unique and easily distinguished from pellagra and other diseases involving the cerebral white matter, but there is nothing consistently characteristic about the resultant mental symptoms, and they may appear years before the anemia. These facts are illustrated in the case history of a 44-year-old housewife who suffered a severe mental disturbance with paranoid symptoms so severe as to necessitate institutional treatment. Ultimately all symptomatic therapy was discontinued, and intramuscular injections of vitamin B12 sufficed to bring about a complete mental restoration. Since none of the mental symptoms is distinctive and the blood changes may appear late, the early diagnosis depends on the physician's alertness to this possibility. Early treatment is necessary because the degenerative changes can be completely reversed only if they are recognized in time.
Wiener JS, Hope JM. CEREBRAL MANIFESTATIONS OF VITAMIN B12 DEFICIENCY. JAMA. 1959;170(9):1038–1041. doi:10.1001/jama.1959.03010090028006
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