Spinal MRI Supporting Myelopathic Origin of Early Symptoms in Unsuspected Cobalamin Deficiency

Abstract

We report two patients with subjectively progressive sensory symptoms and gait disturbance due to cobalamin deficiency, but only slight or absent abnormalities on neurological examination. In both patients, spinal MRI provided evidence for a myelopathic origin of the symptoms, disclosing characteristic T₂ hyperintense signal alterations confined to the posterior columns of the cervical and thoracic spinal cord. The patients illustrate the early clinical presentation of subacute combined degeneration (SCD) with a sensory neuropathy starting with acroparesthesia and Lhermitte’s sign. Furthermore, the diagnostic value of spinal MRI for early diagnosis of SCD with characteristic findings is highlighted.

Chronic Renal Failure Promotes Severe Variant of Vitamin B₁₂ Deficiency

“…The MRI shows a very typical pattern with T 2 -weighted hyperintense signal alterations confined to the posterior columns of the spinal cord that can support an early diagnosis [9] . The basis of the SCD treatment is a sufficient cobalamin replacement therapy, usually consisting of daily intramuscular injections (1,000 g) for several weeks, followed by weekly or monthly applications [1] .…”

Lhermitte's sign and vitamin B12 deficiency: case report

“…4,8,22 Increased T2-weighted and decreased T1-weighted signals, with contrast enhancement in the posterior and lateral columns of the spinal cord can be revealed by MRI. [21][22][23] Lhermitte's sign is rare in patients with vitamin B12 deficiency and may improve with specific therapy.…”

Subacute Combined Degeneration of the Cord: Putnam-Dana Syndrome

“…Cobalamin deficiency [22] causes an accumulation of homocysteine and methylmalonic acid. Dysfunction of the methyl transfer pathway may be the cause, but precisely how it causes subacute combined degeneration is uncertain [23]. Anaemia and macrocytosis are absent at presentation in one third of patients with SACD [24].…”