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HISTORY AND CLINICAL FINDINGS Over a period of about 6 weeks a 49-year-old woman developed increasing exercise-dependent dyspnoea. Her general practitioner had diagnosed marked megaloblastic anaemia and she was hospitalised for its further elucidation. She reported to have eaten or drunk nothing but sweets, potato chips, salty pretzels, lemonade, coffee and tea over the last 2 years. Alcohol intake had been reliably denied by her and outsiders. On admission she weighed 106 kg, her height was 167 cm, and she looked anaemic, had dyspnoea and a sinus tachycardia. There was no evidence of external or internal bleeding and the physical examination was otherwise unremarkable. INVESTIGATIONS Laboratory tests showed a haemoglobin concentration of 4.7 g/dl, as well as marked folic and vitamin B12 deficiency. The food items taken by her contain practically no cobalamine and no folic acid. Gastroscopy revealed grade 1 reflux oesophagitis. Malabsorption being excluded (normal Schilling test, no demonstrable autoantibodies against parietal cells, no evidence of exocrine pancreatic insufficiency), the lack of both vitamins and the megaloblastic anaemia caused by it could be explained only by a deficient food intake over several years. TREATMENT AND COURSE After administration of cobalamine (1 mg intramuscularly twice weekly for 6 weeks, then 300 micrograms daily by mouth for 4 weeks) and folic acid (5 mg twice daily for 10 weeks), as well as a well-balanced diet as prescribed by a dietician, reticulocyte and erythrocyte concentrations had quickly risen to normal at a follow-up examination 2 months later. CONCLUSION The case of an anaemia entirely caused by a deficient diet dearly illustrates the need of a well-balanced food intake even in adults.

Background: Mycophenolate mofetil (MMF) is a new immunosuppressant with pharmacodynamic properties comparable to azathioprine. Recent reports found MMF to be effective in inflammatory bowel disease (IBD). Methods: An open-label prospective and uncontrolled multicentre 6 month trial of MMF in combination with steroids was conducted in 24 chronic active IBD patients. A daily steroid demand of ≥ 10 mg prednisone in the preceding 2 months and a Crohn’s disease activity index (CDAI) > 150, or moderate to severe activity according to Truelove, served as criteria for chronic activity. The treatment consisted of a steroid pulse and tapering protocol in combination with MMF 2 g/day. A prednisone dose of 5 mg/day was maintained during months 4–6. The primary end-point was induction and maintenance of remission. Results: Only 10 of 24 patients had achieved remission after 3 months. All but one Crohn’s disease patient had relapsed by the end of the study at 6 months. Depression and migraine necessitated drug withdrawal in two patients. Conclusion: In conclusion, MMF 2 g/day was unable to induce and maintain remission for a period of 6 months in 23 of 24 chronic active IBD patients. Further controlled investigations are required in view of recent conflicting reports.