Autoimmune atrophic gastritis presenting as myelopathy in a young patient

Abstract

We present a 36 year-old male patient complaining from progressive sensory loss on both hands and sensation of chest and abdominal tightness, lasting for five weeks. Neurological examination revealed a mild tetraparesis, glove and sock hyposthesia, C2 to T11 sensory impairment, vibratory anesthesia and proprioceptive errors of lower limbs. Cerebellar tests were normal. Romberg, Babinski and Lhermitte signs were absent. Laboratory tests revealed Hb 14.3 g/dL, mean corpuscular volume 104 fL. Renal and hepatic functions, iron study, copper levels and angiotensin conversion enzyme, and folic acid were normal. Vitamin B12 level was <82 pg/mL (189-883 pg/mL). Serum immunology, virology and bacteriology were negative. CSF study and brain MRI were unremarkable. Cervical spine MRI showed hyperintense spinal cord signal on T2-weighted images affecting mainly dorsal, but also lateral, columns between medulla oblongata and T11 levels, with subtle contrast enhancement (Fig A-C). Basing on clinical and laboratory examinations, the patient was evaluated for extensive myelopathy due to VBD, and it was performed an upper gastrointestinal examination which revealed an atrophic mucosa; histological examination showed chronic atrophic gastritis and intestinal metaplasia, excluding Helicobacter pylori infection. Anti-parietal cells were negative, but anti-intrinsic factor antibodies were positive. Treatment was performed with IM cyanocobalamin replacement, 1,000 μg IM daily for a week, then weekly for four weeks and monthly afterwards. Three months later, there was a significant clinical recover, only remaining hypoesthesia of hand fingers. MRI performed at this time showed an exuberant improvement (Fig D).Subacute combined degeneration (SCD) refers to degeneration of the posterior and sometimes lateral columns of the spinal cord usually as a result of VBD, which effects may not be appreciated until several years, since there is a significant body store of vitamin B 12 1,2 . Its absorption occurs via the ileal microvilli after binding to the intrinsic factor 3 , and malabsorption