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Generally, very low levels indicate deficiency, whilst borderline results may require further investigation Holotranscobalamin (active B12): Used by some UK laboratories as a first-line or second-line test, measuring the biologically active fraction of B12 [11] [12] Full blood count (FBC): May reveal macrocytic anaemia (enlarged red blood cells) characteristic of B12 deficiency Serum folate: Usually checked concurrently as deficiencies can coexist Additional tests if diagnosis is uncertain may include methylmalonic acid and homocysteine levels, which become elevated in B12 deficiency Investigating the underlying cause is essential and may involve: Intrinsic factor antibodies: Specific but not highly sensitive for pernicious anaemia [14] [15] Gastric parietal cell antibodies: Less specific but can support diagnosis when positive Assessment for malabsorption disorders Dietary evaluation, particularly in vegans or those with restricted diets It is important not to start B12 supplements before testing, as this can interfere with accurate diagnosis

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The melanotic macule typically appears as a small, well-circumscribed, brown-to-black flat macule on the lip or mucous membranes, caused by increased melanin in the basal layer

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