Freitag, 26. Juni 2009

Combined-System Disease

A 76-year-old woman presented with a 3-month history of bilateral numbness and tingling in her hands and feet. She also noted tingling along her spine on forward flexion of the neck (Lhermitte's sign). Her gait was unsteady, particularly when walking in the dark. She noted progressive difficulty with memory. She reported no changes in her bowel and bladder habits, vision, speech, or hearing. On examination, there were areas of hypoesthesia to light touch, extending from the wrist to the fingertips, the palmar surfaces of both hands, and over the toes in both feet. Vibratory and joint-position sensations were decreased bilaterally in the fingers and toes. Romberg's sign was present. She was unable to walk with a tandem gait. Sagittal T2-weighted magnetic resonance imaging (MRI) showed hyperintense signal in the dorsal spinal cord (Panel A, arrows) extending from C2 to C5. Axial T2-weighted MRI showed hyperintense signal localized in the dorsal columns (Panels B and C, arrows) and less obvious in the lateral columns (arrowheads).
The Schilling test showed evidence of pernicious anemia. The patient's vitamin B12 level was below the detectable range (<100 pg per milliliter [74 pmol per liter]). Treatment with B12 injections was begun, and she had clinically significant improvement, over a 6-month period, in her memory, balance, and sensory function.

Carl B. Heilman, M.D. Vasilios A. Zerris, M.D., M.P.H.
NEJM Volume 360:2655 June 18,2009 Number 25

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