Clinical Image Description

      A 27-years-old female was referred to the neurological clinic for evaluation due to difficulty in walking by psychatric service. Depressive symptoms had started 3 months before the neurological complaint associated with visual hallucinations. The patient’s neurological examination showed space and time disorientation, normal muscle tonus and muscle strength in limbs, pallhypestesia and areflexia in both lower extremities, sensory ataxia, unsteadiness of gait. Blood test revelead serum vitamin B12 of 50pg/ml (210-980pg/ml).

      Anti-parietal antibodies were detected, but no antibodies again intrinsic factor. Gastroscopy showed atrophic gastritis. Standard electroneuromyography demonstrated axonal sensory polyneuropathy. Brain Magnetic Resonance Image (MRI) disclosed hyperintense signal in corticospinal tracts, a similar pattern observed in motor neuron disease (Figure 1). The patient was treated with parenteral cyanocobalamin with improvement of neurological and psychotic symptons.

      Cobalamin (Vitamin B12) deficiency is associated with various neurological manifestations, including polyneuropathy, myelopathy, cognitive decline, and rarely epilepsy [1]. The manifestions in brain MRI are diverse, periventricular focal or confluent white matter lesions are commonly found patterns [2]. Several leukoencephalopathy and hyperintense subcortical lesions T2W/DWI (diffusion weighted imaging) have also been described [3,4].

      The case illustrates an unusual MRI lesion pattern in B12 deficiency with signal hyperintensity of the corticospinal tract on T2/FLAIR. The corticospinal tract hyperintense on T2/FLAIR is a simple and sensitive upper motor neuron degeneration marker in clinically verified in motor neuron disease, in particular amyotrophic lateral esclerosis [5]. This case demonstrates that in addition to the variety of clinical presentations in vitamin B12 deficiency, atypical brain imaging patterns can be found.

References

1. Briani C, Dalla Torre C, Citton V, et al. Cobalamin deficiency: clinical picture and radiological findings. Nutrients. 2013; 5 : 4521–39.
2. Chen H, Li H, Li Y, et al. Clinical and imaging characteristics of subacute combined degeneration complicated with white matter lesions in thebrain: A reportoffive cases. Somatosens Mot Res. 2018; 35: 119-123.
3. Kremmyda O, Forbrig, R, Heirinch J, et al. Subcortical lesions due to cobalamin deficiency: Na usual MRI lesion pattern. Nutri Neurosci. 2019; 27: 1-5.
4. Pacheco FT, Scoppetta TL, Sznier M, Paes RA, Rocha AJ. Acute demyelination with leuko encephalopathy and cerebellar involvement in vitamin B12 deficiency. Arq Neuropsi quiatr. 2015; 73: 257.
5. Jin J, Hu F, Zhang Q, Jia R, Dang J. Hyper intensity of the corticospinal tracton FLAIR: A simple and sensitive objectiveupper motor neuron degeneration marker in clinically verified amyotrophic lateral sclerosis. J Neurol Sci. 2016; 367: 177-183.