Rapid healing of a patient with dramatic subacute combined degeneration of spinal cord: a case report

Abstract

BackgroundPrevalence of cobalamin deficiency is high especially in older patients and an immediate therapy start is necessary to prevent irreversible neurological damages. Unfortunately, the diagnosis of cobalamin deficiency is difficult and at present, there is no consensus for diagnosis of this deficiency. Therefore, we aim to elucidate a meaningful diagnostic pathway by a case report with an initially misleading medical history.Case presentationA 57 year-old Caucasian man suffering from dramatic myelosis of the cervical posterior columns. Apart from associated neurological symptoms (tactile hypaesthesia, reduced vibration sensation, loss of stereognosis and of two-point-discrimination) there were no further complaints; especially no gastrointestinal, haematological or psychiatric disorders were provable. Cobalamin (vitamin B12) serum level was normal. The diagnosis of subacute combined degeneration of spinal cord was confirmed by an elevated methylmalonic acid, and hyperhomocysteinemia. Cobalamin deficiency was caused by asymptomatic chronic atrophic inflammation of the stomach with a lack of intrinsic factor producing gland cells. This was revealed by increased gastrin and parietal cell antibodies and finally confirmed by gastroscopy. Parenteral substitution of cobalamin rapidly initiated regeneration.ConclusionsThis case demonstrates that normal cobalamin serum levels do not rule out a cobalamin deficiency. In contrast, path-breaking results can be achieved by determining homocysteine, holotranscobalamin, and methylmalonic acid.

Subacute Combined Degeneration: A Retrospective Study of 68 Cases with Short-Term Follow-Up

“…Instead, the levels of methylmalonic acid, homocysteine [9], and holotranscobalamin (known as “active B 12 ”) [12] are better biomarkers for diagnosis of vitamin B 12 deficiency. Therefore, a normal serum vitamin B 12 level cannot be used to exclude genuine vitamin B 12 deficiency [13] and damage in this condition. The term “functional vitamin B 12 deficiency” [9] is thus used to take the above considerations into account.…”

“…Different treatments for vitamin B 12 deficiency have been described in the literature [1, 13-16]. To our knowledge, there are as yet no guidelines regarding a therapeutic regimen for patients with SCD.…”

Megaloblastic Pancytopenia Mimicking Hellp Syndrome in Late Pregnancy: A Case Report

“…Index case presented in a sick condition with severe anemia, low platelet and hemolysis, prompting clinician to suspect HELLP syndrome. However low leukocyte count is unusual in HEELP unless disseminated intravascular coagulopathy (DIC) ensue (5).…”

Subacute Progressive Myelopathy: Transverse Myelitis or Subacute Combined Degeneration? A Case Report

“…The finding of a band of thoracic sensory impairment would not be expected with SCD and would be more compatible with TM. A review of the literature identified that both sensory levels and bands of abnormal sensation on the chest have been reported in SCD [3–5]. Although a sensory level might be explained by rare spinothalamic tract involvement [5], there is no satisfactory explanation for the band of abnormal sensation.…”

“…Clearly defined sensory level [1] May have thoracic sensory level due to spinothalamic tract involvement [3,5] or band of abnormal sensation on thorax [4,5] Painful, circumferential band of reduced pinprick and temperature at T5eT6 enlargement and no gadolinium enhancement, considered likely TM ( Figure 1A). Brain, thoracic, and lumbosacral spine images showed no abnormalities.…”