A 49-year-old woman presented with progressive ascending quadriparesis associated with paresthesias and recent wide-based gait. Cognitive impairment associated with reduced vibration and proprioception sense was observed. Brain MRI documented the presence of extensive white matter demyelination (Figure 1). Megaloblastic anemia, low B12 level and chronic gastritis were confirmed (Figure 2).
(A) FLAIR images demonstrated signal hyperintensity in the supra- and infratentorial white matter, (B) which was restricted to the corticospinal tracts in the subcortical pre-central gyri. (C) Restricted diffusion was only observed in the cerebellum, (D) consistent with the patient’s recent cerebellar symptoms and associated with gadolinium enhancement.
(A and B) Endoscopic biopsy illustrating the presence of chronic gastritis with intestinal metaplasia.
Vitamin B12 acts as a coenzyme in the methylmalonyl-CoA mutase reaction, essential for
myelin biosynthesis11 Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-60
http://dx.doi.org/10.1056/NEJMcp1113996
https://doi.org/10.1056/NEJMcp1113996...
. This vitamin
deficiency may result in a variable neurologic presentation11 Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-60
http://dx.doi.org/10.1056/NEJMcp1113996
https://doi.org/10.1056/NEJMcp1113996...
,22 Tangney CC, Aggarwal NT, Li H, Wils9on RS, Decarli C, Evans DA et
al. Vitamin B12, cognition, and brain MRI measures: a cross-sectional
examination. Neurology. 2011;77(13):1276-82.
http://dx.doi.org/10.1212/WNL.0b013e3182315a33
https://doi.org/10.1212/WNL.0b013e318231...
, including spinal cord, brain and cerebellar involvement. Our
report supports the importance of performing diffusion and intravenous contrast
administration to evaluate MRI evidence of acute demyelination in this setting.
References
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1Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-60 http://dx.doi.org/10.1056/NEJMcp1113996
» https://doi.org/10.1056/NEJMcp1113996 -
2Tangney CC, Aggarwal NT, Li H, Wils9on RS, Decarli C, Evans DA et al. Vitamin B12, cognition, and brain MRI measures: a cross-sectional examination. Neurology. 2011;77(13):1276-82. http://dx.doi.org/10.1212/WNL.0b013e3182315a33
» https://doi.org/10.1212/WNL.0b013e3182315a33
Publication Dates
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Publication in this collection
Mar 2015
History
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Received
25 Nov 2014 -
Accepted
16 Dec 2014