Images in clinical medicine. Vitiligo and pernicious anemia.

A 45-year-old woman with a 17-year history of vitiligo (panel A) was evaluated because of persistent fatigue. She was found to have pancytopenia (white-cell count, 3200 per cubic millimeter; hemoglobin level, 8.1 g per deciliter; and platelet count, 147,000 per cubic millimeter) with macrocytosis (mean corpuscular volume, 125 μm3) and hypersegmented polymorphonuclear leukocytes (Panel B; hematoxylin and eosin, ×100). The serum vitamin B12 level was 84 pmol per liter (normal range, 220 to 660). The serum folate level was normal. Erythroid hyperplasia with left-shifted megaloblastic erythropoiesis and giant metamyelocytes (Panel C, arrow; hematoxylin and eosin, ×100) was seen . . .