Meat of the Matter: Rehabilitation of Myeloneuropathy Due to Vitamin B12 Deficiency

Case Diagnosis: Vitamin B12 deficiency

Case Description or Program Description: 35-year-old female with psoriatic arthritis and recent prolonged viral gastrointestinal illness presented to the ED after 6 weeks of progressively worsening bilateral leg paresthesias ascending to the hands, leading to multiple falls. On exam, she had length-dependent diminished vibratory sensation and impaired proprioception, including positive Romberg sign and pseudoathetosis of the hands. Labs showed low serum Vitamin B12 and Vitamin B6. Additional history-taking revealed patient follows a vegetarian diet. Differential included other nutritional etiologies including copper poisoning or Vitamin E deficiency, or atypical GBS. Work-up included LP (unremarkable), EMG (reduced amplitude in sensory nerves), and MRI Total Spine (no cord edema). She was started on intramuscular Vitamin B12 repletion and transferred to inpatient rehabilitation.

Setting: Inpatient rehabilitation hospital

Assessment/Results: At time of transfer, patient’s functional status was limited by sensory ataxia. She was treated with compression garments to increase proprioceptive input. She also had burning sensation in the legs that responded to gabapentin, as well as a transition from home venlafaxine to duloxetine. She had residual right foot drop for which a posterior leaf spring orthosis improved ambulation with rolling walker. Section GG scores increased from 31 (admission) to 42 (discharge) for ADLs and from 20 to 24 for mobility, indicating full independence. After 2 weeks, patient was discharged home with close supervision.

Discussion (relevance): Vitamin B12 deficiency is a rare diagnosis in younger patients but can occur in the setting of atrophic gastritis or intestinal malabsorption due to bariatric surgery or autoimmune disease (eg. Crohn’s, celiac, scleroderma). In this patient it seems likely due to recent viral gastrointestinal illness in addition to vegetarian diet.

Conclusions: This case report shows excellent results after inpatient rehab stay of a patient with myeloneuropathy due to Vitamin B12 deficiency.