Neuromyelitis optica spectrum disease coexisting with subacute combined degeneration: a case report.

BACKGROUND: Subacute combined degeneration (SCD) is a demyelinating disease characterized by vitamin B12 deficiency related segmental degeneration of the dorsal or lateral columns of the spinal cord. However, few cases have been reported as a comorbidity of SCD and neuromyelitis optica spectrum disease (NMOSD). CASE PRESENTATION: Herein, we describe a female patient (61-year-old) who had sensory deficits, paresthesia, and weakness of the distal extremities for over 2 months. She then received an initial diagnosis of SCD with typical inverted "V-sigh" hyperintensities over the posterior aspect of the spinal cord in magnetic resonance imaging (MRI - T2-weighted imaging), as well as megaloblastic anaemia in blood examinations. From the past history, there was no evidence of a dietary deficiency or gastric abnormalities. However, traditional treatment with vitamin B12 supplementation was ineffective. Hence, a demyelinating antibody examination showed that she had antibodies targeting aquaporin 4 (AQP4) in both the cerebrospinal fluid and serum, leading to the diagnosis of NMOSD. Her clinical symptoms were obviously improved after treatment with intravenous glucocorticoids. CONCLUSION: People who have nutritional deficiency or altered gastrointestinal function are more likely to develop SCD. This case raises the awareness that the poor therapeutic effects of simple vitamin B12 supplementation could be explained by immunoreactions against AQP4. A better recognition will be of great importance for the correct diagnosis of the comorbidity, as well as for essential treatment and even a better prognosis.

An unusual case of subacute combined degeneration due to nitrous oxide abuse, which relapsed after bariatric surgery: A case report.

RATIONALE: Several studies have reported subacute combined degeneration (SCD) induced by nitrous oxide (N2O) abuse. However, few studies have reported that N2O-induced SCD recurred because of sleeve gastrectomy after neurological symptoms improved. PATIENT CONCERNS: We report the case of an 18-year-old woman who developed paresthesia, weakness in 4 limbs, and an unstable gait after frequent, excessive N2O inhalation. DIAGNOSIS: The patient was diagnosed as having SCD. INTERVENTIONS AND OUTCOMES: Nineteen days after intravenous mecobalamin and supplementation with other kinds of vitamin B, her weakness and paresthesia resolved. However, 7 months after discharge, the patient experienced recurrence following sleeve gastrectomy. Blood biochemistry revealed low vitamin B12 levels. After a 22-day treatment, similar to the first hospitalization, her residual numbness and unsteady gait improved. LESSONS: This case highlights that patients, especially those at high risk of vitamin B12 deficiency, undergoing sleeve gastrectomy require careful nutritional follow-up and routine monitoring of micronutrients such as vitamin B12 and homocysteine. Continuous vigilance is essential for patients with common and rare neurological complications.

Subacute Combined Degeneration of the Spinal Cord Caused by Autoimmune Gastritis.

A 68-year-old woman presented with a 2-year history of worsening unsteady gait. Her neurological examination revealed peripheral neuropathy with lower limb sensory dominance. T2-weighted imaging revealed a disorder of the posterior cervical cord. Blood test findings revealed vitamin B12 deficiency, and gastroscopy revealed typical findings of autoimmune gastritis. She received vitamin B12 supplementation, but some peripheral neuropathy symptoms persisted due to longstanding vitamin B12 deficiency. Asymptomatic patients should undergo gastroscopy to detect autoimmune gastritis, as chronic vitamin B12 deficiency causes irreversible peripheral neuropathy.

Subacute combined degeneration associated with vitamin E deficiency due to small bowel obstruction: A case report.

RATIONALE: There have been a few reported cases of subacute combined degeneration (SCD) associated with vitamin E deficiency, but the period of intestinal malabsorption was more than several years. We present a rare case of acute onset SCD that occurred in a relatively short period of several weeks with vitamin E deficiency related to small bowel obstruction. PATIENT CONCERNS: A 50-year-old woman had abdominal pain. A small bowel obstruction was suspected and conservative treatment was performed. She underwent bowel surgery after 2 weeks without any improvement. Following the operation, she was in a state of reduced consciousness. She was treated in an intensive care unit. Her consciousness level gradually recovered to alert in a week, but other symptoms such as ataxia, weakness on limbs, severe dysarthria, and dysphagia occurred. Since then, she had spent nearly 6 weeks in a bed-ridden state without improving. DIAGNOSIS: SCD associated with vitamin E deficiency was confirmed by laboratory investigations, electrophysiologic test, and whole spine magnetic resonance imaging scans. INTERVENTIONS: For vitamin E supplementation, she was administered a dose of 1200 mg/d. Physical therapy was focused on strengthening exercise, balance, and walker gait training. Occupational therapy was focused on activities of daily living training and dysphagia rehabilitation. OUTCOMES: After 6 weeks, her muscle strengths and functional level were substantially improved. The vitamin E level was recovered to normal range. LESSONS: This case suggests that if neurological symptoms occur in patients with intestinal obstruction, clinicians need to consider a deficiency of micronutrients such as vitamin E and vitamin B12. Patients with short clinical courses suffer less neurological damage and achieve faster recovery.

Subacute combined degeneration of the spinal cord is associated with tripterygium glycoside tablet usage.

BACKGROUND: Subacute combined degeneration (SCD) is a neurodegenerative disease caused by vitamin B12 deficiency. The lesions mainly involve the posterior cord, lateral cord, and peripheral nerves. Occasionally, the lesions also involve brain white matter and optic nerves in severe cases. Reports of drug-induced impaired absorption and metabolism of vitamin B12 resulting in SCD are scarce. INTRODUCTION: A patient developed SCD after long-term use of tripterygium glycoside tablets in the treatment of glomerulonephritis. However, after discontinuation and vitamin B12 treatment with tripterygium glycoside tablet, the symptoms of SCD were significantly resolved. CONCLUSION: Drug-induced SCD is a less commonly reported cause of the disease. Tripterygium glycoside tablets can induce adverse reactions in the digestive system, causing damage to absorption and metabolism of vitamin B12. Physicians should be aware of the possibility of tripterygium glycoside tablet-induced SCD after excluding more common causes such as inadequate dietary intake and impaired absorption due to gastrointestinal diseases or genetic disorders.

Degeneración combinada subaguda de la médula espinal por deficiencia de vitamina B12 / Subacute combined degeneration of the spinal cord due to vitamin B12 deficiency

Introducción: la degeneración combinada subaguda de la médula espinal es una mielopatía inducida por deficiencia de vitamina B12. Produce disestesias simétricas, alteraciones de la sensibilidad superficial y vibratoria. En estadios avanzados causa defectos de la memoria, el aprendizaje, comportamiento, gusto y olfato.Objetivo: presentar el caso de una paciente diagnosticada y tratada por degeneración combinada subaguda de la médula espinal, afección rara en Cuba.Presentación del caso: paciente femenina, de 50 años de edad. Refirió que dos años antes del ingreso presentó debilidad progresiva en los miembros inferiores, añadiéndose frialdad y adormecimiento de las cuatro extremidades, marcha tambaleante, palpitaciones, fatiga, cefalea, disnea de esfuerzo y tinte de la piel de color amarillo limón. Se le realizaron exámenes complementarios de laboratorio, imagenológicos e histológicos. La lámina periférica mostró anisocitosis y macrocitosis marcadas, presencia de poiquilocitos y policromatofilia. A la paciente se le administró diariamente, en dosis única, 100 mg de vitamina B12 durante 10 días, con recuento leucocitario diario. Fue egresada a los 15 días, con indicaciones para seguir el tratamiento. Transcurridos tres meses recuperó 70 por ciento de sus capacidades cognitivas y motoras, con movilidad de las cuatro extremidades.Conclusiones: el diagnóstico de esta enfermedad precisa de una correcta aplicación del método clínico, y la realización de exámenes de laboratorio, imagenológicos e histológicos. Ello fue posible por la atención multidisciplinaria entre los especialistas de medicina interna, hematología, imagenología y gastroenterología. En este caso la edad de la paciente no estaba comprendida en el rango de presentación de la enfermedad(AU)

Introduction: subacute combined degeneration of the spinal cord is a myelopathy induced by vitamin B12 deficiency. It produces symmetric dysesthesias, alterations of superficial and vibratory sensitivity. In advanced stages it causes defects of memory, learning, behavior, taste and smell.Objective: to present the case of a patient diagnosed and treated by subacute combined degeneration of the spinal cord, a rare condition in Cuba.Case presentation: female patient, 50 years old. She reported that two years before admission she presented progressive weakness in the lower limbs, adding coldness and numbness of the four limbs, wobbly march, palpitations, fatigue, headache, dyspnea and lemon yellow skin tint. She was given complementary laboratory, imaging and histological exams. The peripheral lamina showed marked anisocytosis and macrocytosis, presence of poikilocytes and polychromatofilia. The patient was given daily, in a single dose, 100 mg of vitamin B12 for 10 days, with daily white blood cell count. She was discharged 15 days after, with instructions to continue the treatment. After three months she recovered 70 percent of her cognitive and motor skills, with mobility of the four limbs.Conclusions: the diagnosis of this disease requires a correct application of the clinical method, and the realization of laboratory, imaging and histological exams. This was possible due to the multidisciplinary care among specialists in internal medicine, hematology, imaging and gastroenterology. In this case, the age of the patient was not included in the range of presentation of the disease(AU)

Pitfalls in the diagnostic evaluation of subacute combined degeneration.

We report a case of a 43-year-old man presenting with a 2-week history of painless ascending sensory disturbances, suspected to be suffering from acute inflammatory polyneuropathy. On clinical examination, deep tendon reflexes were preserved and muscle strength was 5/5 everywhere. Gait was ataxic with positive Romberg test. Lumbar puncture was normal and electroneurography demonstrated demyelination. With spinal cord involvement centred on the posterior tracts on MRI, differential diagnosis focused on cobalamin deficiency. Initial laboratory work up showed nearly normal holotranscobalamin (43 pmol/L, normal>50) suggesting no vitamin B12 deficiency. Surprisingly, further testing including methylmalonic acid (3732 nmol/L, normal<271) and homocysteine (48.5 µmol/L, normal<10) showed an impairment of vitamin B12-dependent metabolism leading to the diagnosis of subacute combined degeneration. Only after repeated history taking did the patient remember having taken tablets containing cobalamin for 3 days before hospitalisation. In case of B12 deficiency, holotranscobalamin can rapidly normalise during supplementation, whereas methylmalonic acid and homocysteine might help to detect B12 deficiency in patients who recently started supplementation.

Copper deficiency myelopathy and subacute combined degeneration of the cord - why is the phenotype so similar?

Copper deficiency myelopathy (CDM) is an increasingly recognised mimic of subacute combined degeneration (SCD) of the cord due to cobalamin (vitamin B(12)) deficiency. It has been suggested that copper deficiency induces myelopathy through dysfunction of cytochrome oxidase, which is known to be copper-dependent. However, cytochrome oxidase is not cobalamin-dependent, so this hypothesis fails to explain the phenotypic similarity between CDM and SCD. We propose that the first step in a final common pathway of CDM and SCD is dysfunction of the methylation cycle. This cycle includes both copper and cobalamin-dependent enzymes and catalyses the net transfer of a methyl group from methyltetrahydrofolate to a variety of macromolecules, including myelin proteins. Dysfunction of the cycle might therefore cause failure of myelin maintenance and ultimately myelopathy. One step of the methylation cycle is catalysed by methionine synthase, which is known to be cobalamin-dependent. Nitrous oxide specifically inhibits this enzyme by inactivating methylcobalamin, causing SCD in animals and humans. Both animal and human data suggest that methionine synthase also requires copper, implying that the enzyme may be involved in the pathogenesis of CDM. Another enzyme involved in the methylation cycle, S-adenosylhomocysteine hydrolase, may be regulated by copper. Although this enzyme is not cobalamin-dependent, its potential impairment in copper deficiency may contribute to the overall dysfunction of the methylation cycle. In cases of congenital deficiencies of methylation cycle enzymes, spinal and cerebral demyelination was observed, providing further support for a critical role of the methylation cycle in myelination. Biochemical dysfunction of the methylation cycle has been reported in HIV myelopathy, which has pathological parallels with SCD. This raises the possibility that other demyelinating myelopathies might involve an impairment of the methylation cycle. Our hypothesis could be tested by measuring CSF concentrations of methylation cycle intermediates in cases of CDM, as these reflect spinal cord tissue levels. If it were confirmed, the hypothesis would not only provide a plausible explanation for the phenotypic similarity between CDM and SCD, but might also open up further therapeutic options such as methionine and betaine supplementation.

Contribution of spinal MRI for unsuspected cobalamin deficiency in isolated sub-acute combined degeneration.

Sub-acute combined degeneration (SCD) is a rare cause of demyelination of the dorsal and lateral columns of the spinal cord and is a neurological complication due to vitamin B12 deficiency. Revealing forms of SCD without anemia are rare. We report a case of SCD of the spinal cord in a 33-year-old woman without anemia but with a 10-month history of paresthesis and urine imperiosity. Magnetic resonance imaging (MRI) of the spine showed intramedullary hyperintensity seen on T2-weighted images in the posterior column of the cervico-dorsal spinal cord, extending from C1 to D1. A diagnosis of SCD of the spinal cord was considered and confirmed by a low serum cobalamin. The patient was treated with vitamin B12 supplements and showed gradual improvement in her clinical symptoms.