CASE PRESENTATION BY JYOTHIS THANKAM

H ISTORY A male patient named Pradeep 35 yr old a manual labourer hailing from a low socioeconomic status came with the following complaints Difficulty in walking for 3 months Blurring of vision for 2 months Tinnitus and vertigo for 2 months

H/O presenting complaints patient complains of swaying while walking -3 months-which was gradual in onset and progressive in nature. Difficulty more at night Visual blurring-2months

PAST H/O No h/o DM,HT, EPILEPSY and TB No relevant drug h/o PERSONAL H/O Chronic Alchoholic for 20 yrs No smoking Tobacco chewing Takes Mixed Diet No Sexual Promiscuity FAMILY H/O No h/o neuropathy,ataxia, epilepsy

GENERAL EXAMINATION Patient is conscious,co-operative, well oriented, moderately built and nourished Bitot’s spots,angular stomatitis –present Greying of Hair Discolouration of Moustache VITAL SIGNS Pulse rate-60 beats/min BP-150/100mmhg RR-18 cycles/min Temp-afebrile

CNS EXAMINATION Patient is alert with normal speech RELEASED REFLEXES -absent EXAMINATION OF CRANIAL NERVES Visual Acuity –B/l Reduced Hearing - Normal Examination of motor system Strength of muscle lower limb-grade 4+ upperlimb –normal

All superficial reflexes appears to be normal Deep reflexes ALL preserved Ankle reflex-reduced Gait-High Stepping, Uses visual clues for walking Test for coordination and movements Finger nose test-negative Heel to knee test-positive No involuntary movements

E XAMINATION Visual acuity –Reduced B/l B/l optic Atrophy Hearing –Normal Motor-No motor Weakness Examination of sensory system Primary sensation impaired in LL-stockings distribution Position sense impaired in lower limbs Romberg’s Positive

I NVESTIGATION Hb-8mg% CT head-Normal NCS-Sensory nerve conduction impaired. VEP-Delayed P100 on Rt side VDRL-Negative

D IFFERENTIAL D IAGNOSIS -S ENSORY A TAXIA B-12 Deficiency Syphilis-VDRL-Negative Hereditary-No Family History Treatment Given Inj B-1,B6.B12 Condition At Discharge-Improved

VITAMIN B12 Source- meat, milk, eggs, fish. Normal amount-5-30microgm. Absorbed by IF present in stomach and transported to plasma and binds to transcobalamin II and will be carried to tissues for utilisation. Normaly level falls during pregnancy.

CAUSES OF VITAMIN B12 DEFICIENCY Dietary deficiency. Gastric factors. Pernicious anaemia. Small bowel factors.

NEUROLOGICAL FINDINGS IN B12 DEFICIENCY Peripheral nerves Glove &stocking paraesthesia. Spinal cord Subacute combined degeneration Diminished vibration &proprioception UMN signs in cortico spinal tracts Cerebrum – Dementia optic atrophy Autonomic neuropathy

Subacute combined degeneration of spinal cord ? Treatable myelopathy present with sub acute paraesthesias in hands and feet,loss of vibration and position sensation,and a progressive spastic and ataxic weakness Signs-loss of reflexes& babinskinsky sign + Optic atrophy,irritability&other mental changes in advanced stages

DIAGNOSIS Low serum cobalamin level Raised level of methylmalonic acid&homocysteine Macrocytic red blood cells + Schilling test +

TREATMENT Replacement therapy starts with 1000 microgm of vit B12 I.V at regular intervals or by oral treatment.

THANK YOU