A 62 years old patient arrived at the Centre for Diabetes, Nutrition and Metabolic Diseases presenting with fatigability, headache, dizziness, dyspnea during moderate effort, palpitations, nausea, bloating and epigastric pain and in the right hypochondrium. We mention that no other neurological signs have been described. Given the symptoms, it was decided to admit the patient in the Diabetes, Nutrition and Metabolic Diseases Clinic for further investigations and establishing the correct course of treatment.
The patient included in the study signed the informed consent for the acquisition, analysis, and publishing of the anonymized data collected. Since no personal identification data were used in this manuscript, the ethics committee approval is not needed.
It needs to be mentioned that the patient had been diagnosed with Type 2 Diabetes Mellitus in 2015 and was undergoing treatment with metformin 1 g twice a day and sitagliptin 100 mg once a day. Metformin treatment had been initiated at the time of diagnosis (2015), and sitagliptin had been added to the therapeutic plan in 2018. The patient had been presenting for evaluation visits every three months since being diagnosed with Type 2 Diabetes Mellitus.
Also, the patient was receiving treatment with beta-blocker (Bisoprolol 5 mg/day), ACE inhibitor (Perindopril 10 mg/day) as well as a thiazide diuretic (Indapamide 1.5 mg/day).
The patients' history did not reveal alcohol abuse or smoking, the physical exam revealed obesity grade II (BMI=37 kg/m2) and an abdominal circumference (AC) of 116 cm, skin paleness and slight dehydration, rhythmic heartbeat, blood pressure of 105/70 mmHg, a pulse of 92 b/min, no pathological heart murmurs and a glycaemia equal to 220 mg/dl.
Blood tests revealed an unsatisfactory glycemic control, quantified by an HbA1c of 9.8% as well as a low HDLc level of 29 mg/dl, while renal function and hepatic function were normal.
The blood panel presented severe modifications prompting more detailed investigations in order to determine the cause of the anemia: Hb= 8.7 g/dl, Ht= 29%, H= 2.3 x106/microL, L= 5.9x103/microL, T= 191 x103/microL, MEV= 119.6 fl, MEH= 39 pg, MECH= 34 g/dl. Iron levels were normal 77 microg/dl (normal values being between 50 and 170 micro/dl).
According to WHO, anemia is defined by a Hb level under 13 g/dl in men and under 12 g/dl in women. If the mean volume of erythrocytes is greater than 100 fl, one could consider macrocytic anemia, the most common form encountered being megaloblastic anemia.
Given the hematologic panel, a peripheral blood smear was performed, and it identified anisocytosis with hypochromic erythrocytes, macrocytes, codocytes, isolated thrombocytes as well as thrombocytes in small or medium groups.
Considering the poor glycemic control, as well as high glycemic values and clinical symptoms, treatment with oral antidiabetics drugs was stopped, and insulin therapy was initiated in a basal-bolus regimen, with dosages adjusted according to glycemic values. Consecutive to treatment modification, it was noticed that the patients' symptoms had significantly improved, dyspnea and gastric discomfort were disappeared. An EKG, chest X-ray, abdominal echography and gastroscopy were performed. These investigations did not reveal any notable pathological changes, significant to other conditions. Vitamin B12 and folate were measured. Results showed that the concentration of B12 was very low: 113 pmol/l (normal values are between 191 and 663 pmol/l for the European population) and serum concentration of folate was in normal range: 18.6 ng/mL (normal values are between 4.6 and 34.8 ng/mL).
Substitution treatment with vitamin B12 was initiated in the form of intramuscular injection, initially with 1000 microg/week, over the first 2 months, consecutively the dosage being reduced to 1000 microg every 2 weeks.
For obtaining a good glycemic control, the administration of a long-acting insulin analogue (Glargine) once daily (at bedtime) in association with sitagliptin 100 mg/day (in the morning) was the preferred option.
After 3 months the patient was re-admitted in the Diabetes Clinic for re-evaluation: Table 1 presents the main biological parameters investigated at the time of diagnosis as well as 3 months after substitution treatment. 
Glycemic control was significantly improved, having a decrease of HbA1c of 1.6 pp (from 9.8% to 8.2%) (Table 2).