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Clinical manifestations The primary clinical manifestations of cobalamin deficiency are described in Table 2 They are highly polymorphic and of varying severity, ranging from milder conditions, such as the common sensory neuropathy and isolated anomalies of macrocytosis and hypersegmentation of neutrophils, to severe disorders, including combined sclerosis of the spinal cord, hemolytic anemia and even pancytopenia.2 , 4 , 14 , 37 Among the classic manifestations are Hunter's glossitis, which causes the lingual papillae to atrophy, making the tongue look smooth and shiny, and neuroanemic syndrome