title: Rapid healing of a patient with dramatic subacute combined degeneration of spinal cord: a case report.
abstract: BACKGROUND
  Prevalence of cobalamin deficiency is high especially in older patients and an immediate therapy start is necessary to prevent irreversible neurological damages. Unfortunately, the diagnosis of cobalamin deficiency is difficult and at present, there is no consensus for diagnosis of this deficiency. Therefore, we aim to elucidate a meaningful diagnostic pathway by a case report with an initially misleading medical history.
  
  
  METHODS
  A 57 year-old Caucasian man suffering from dramatic myelosis of the cervical posterior columns. Apart from associated neurological symptoms (tactile hypaesthesia, reduced vibration sensation, loss of stereognosis and of two-point-discrimination) there were no further complaints; especially no gastrointestinal, haematological or psychiatric disorders were provable. Cobalamin (vitamin B12) serum level was normal. The diagnosis of subacute combined degeneration of spinal cord was confirmed by an elevated methylmalonic acid, and hyperhomocysteinemia. Cobalamin deficiency was caused by asymptomatic chronic atrophic inflammation of the stomach with a lack of intrinsic factor producing gland cells. This was revealed by increased gastrin and parietal cell antibodies and finally confirmed by gastroscopy. Parenteral substitution of cobalamin rapidly initiated regeneration.
  
  
  CONCLUSIONS
  This case demonstrates that normal cobalamin serum levels do not rule out a cobalamin deficiency. In contrast, path-breaking results can be achieved by determining homocysteine, holotranscobalamin, and methylmalonic acid.
authors.affiliation: Department of Neurology, Justus-Liebig-University Giessen, Klinikstraße 33, 35385, Gießen, Germany. florian.roessler@neuro.med.uni-giessen.de.|Klinik und Poliklinik für Neurologie, Universitätsklinikum Standort Gießen, Klinikstraße 33, 35385, Gießen, Germany. florian.roessler@neuro.med.uni-giessen.de.
authors.forename: Florian C
authors.initials: FC
authors.lastname: Roessler
authors.affiliation: Department of Neurology, Justus-Liebig-University Giessen, Klinikstraße 33, 35385, Gießen, Germany.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Wolff
mesh_terms: D000906:Antibodies / Q000737:chemistry; D005755:Gastrins / Q000737:chemistry; D005773:Gastroscopy; D006710:Homocysteine / Q000097:blood; D006801:Humans; D007249:Inflammation; D008297:Male; D008764:Methylmalonic Acid / Q000097:blood; D008875:Middle Aged; D010295:Parietal Cells, Gastric / Q000166:cytology; D013116:Spinal Cord / Q000473:pathology*; D052879:Subacute Combined Degeneration / Q000628:therapy*; D014155:Transcobalamins / Q000737:chemistry; D014806:Vitamin B 12 Deficiency / Q000150:complications
chemical_list: D000906:Antibodies; D005755:Gastrins; D014155:Transcobalamins; D006710:Homocysteine; D008764:Methylmalonic Acid
keywords: Autoimmune gastritis; Cobalamin; Holotranscobalamin; Homocysteine; Methylmalonic acid; Subacute combined degeneration of spinal cord