Interesting read from the Canadian Journal of Neurological Sciences - http://www.cjns.org/26febtoc/mri.html
A 30-year-old African-American woman presented to another hospital with inability to walk, numbness of her trunk and extremities, and urinary and bowel incontinence.
Eighteen months earlier, she had noticed bilateral hand and foot numbness and tingling, which was followed by progressive leg weakness. Eventually she had become wheelchair bound. She was alert, oriented, and depressed. She could move the upper extremities against some resistance, but she was unable to raise the lower extremities off the bed. Only with great assistance could she stand. Sensation was decreased below the T10 level and was absent in the legs. Tendon reflexes were brisk in the upper extremities and absent in the lower extremities.
Hemoglobin was 7.9 g/dL, hematocrit 22.8%, and WBC 1 100/µL. The mean corpuscular volume was 123 fL (nl 80-100 fL). Vitamin B12 level was 60 pg/mL (nl 200-1610 pg/mL) and folic acid was 12.5 ng/mL (nl 3.0-17 ng/mL). The intrinsic factor blocking antibody was positive, the anti-parietal cell antibody was negative, and the Schilling test was consistent with pernicious anemia. Nerve conduction studies and electromyography showed mild peripheral neuropathy, manifest by absent sural sensory responses and distal lower extremity fibrillations. On MRI the brain was normal; however, the spinal cord had increased T2-weighted signal in the posterior columns of the cervical and thoracic regions, mostly at the C3-C8 level. (Figure 1A). In the cervical and upper thoracic spinal cord, the posterior columns showed gadolinium contrast enhancement, marked at the C3-C8 level. At the high cervical region the lateral columns also showed mild enhancement (Figure 1B).
Having been given the diagnosis of pernicious anemia with subacute combined degeneration of the spinal cord, the patient received 7 daily intramuscular vitamin B12 (1000 µg) injections. Thereafter she continued to receive the same dose once weekly. Hypothyroidism was treated with oral levothyroxin (100 mcg/day).
After 20 days of vitamin B12 therapy, the patient was transferred to The National Rehabilitation Hospital. Mental status, language, and cranial nerve examinations were normal, including Humphrey and Goldmann visual field testing. Motor, sensory, and cerebellar examinations were normal in the upper extremities. Although, unable to walk or stand, she could move the right leg against gravity and the left leg against some resistance. Tendon reflexes were absent; a Babinski sign was present on the right. In the lower extremities, vibration sense and proprioception were absent, and sensation to light touch and to pin-***** were decreased.
After 42 days of vitamin B12 therapy the spinal cord MRI was normal (Figure 2). There was improvement in mood. Standing and walking were possible with much assistance. Patellar reflexes were present but ankle reflexes were absent. Light touch and pin-***** sensation were decreased, moderately up the hips and minimally to midthoracic level. Hypersensitivity of the feet to light and noxious stimuli interferred with plantar reflex evaluation.
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