Acute demyelination with leukoencephalopathy and cerebellar
involvement in vitamin B12 deficiencyA 49-year-old woman presented with progressive ascending quadriparesis associated with paresthesias and recent wide-based gait. Cognitive impairment associated with reduced vibration and proprioception sense was observed. Brain MRI documented the presence of extensive white matter demyelination (Figure 1). Megaloblastic anemia, low B12 level and chronic gastritis were confirmed (Figure 2).
(A) FLAIR images demonstrated signal hyperintensity in the supra- and infratentorial white matter, (B) which was restricted to the corticospinal tracts in the subcortical pre-central gyri. (C) Restricted diffusion was only observed in the cerebellum, (D) consistent with the patient’s recent cerebellar symptoms and associated with gadolinium enhancement.
(A and B) Endoscopic biopsy illustrating the presence of chronic gastritis with intestinal metaplasia.
Vitamin B12 acts as a coenzyme in the methylmalonyl-CoA mutase reaction, essential for myelin biosynthesis1. This vitamin deficiency may result in a variable neurologic presentation1,2, including spinal cord, brain and cerebellar involvement. Our report supports the importance of performing diffusion and intravenous contrast administration to evaluate MRI evidence of acute demyelination in this setting.
References
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1Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-60
http://dx.doi.org/10.1056/NEJMcp1113996
» https://doi.org/10.1056/NEJMcp1113996 -
2Tangney CC, Aggarwal NT, Li H, Wils9on RS, Decarli C, Evans DA et
al. Vitamin B12, cognition, and brain MRI measures: a cross-sectional
examination. Neurology. 2011;77(13):1276-82.
http://dx.doi.org/10.1212/WNL.0b013e3182315a33
» https://doi.org/10.1212/WNL.0b013e3182315a33
