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The common systemic features reported were fatigue, glossitis, weight loss and anorexia that was found in 34%, 31%, 27% and 22% of cases respectively.[4] Hyper pigmentation of skin has been reported only rarely as the presenting manifestation of vitamin B12 deficiency as found in this patient.[5] There are only two such Indian reports found in Indian literature.[6,7] After the treatment, hematologic response begins after several days and, moreover, the final hematologic landmark is the blood count, including mean corpuscular volume (MCV) that should be completely normal by the eighth week.[8] The cutaneous manifestation of vitamin B12 deficiency is skin hyper pigmentation, vitiligo, hair changes, and recurrent angular stomatitis

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However, the RDA of 2.4 mcg for people under 50 years of age is much harder to meet on a vegetarian or vegan diet