Biodata
Name: Tuhirirwe Monica
Age: 26 years
Sex: female
Address: Mitooma
Religion: Catholic
Tribe: Munyankole
Date of admission: 12th May 2010
Presenting Complaint
Difficulty in walking x 5/52
Milk coming from the breast x 8/52
History of presenting complaint
She was well until 5 months ago when she developed difficulty to walk. This started gradually but got worse
recently which prompted her to come the hospital. The difficulty in walking has affected her daily life.She says that
she cant walk properly and she walks in zigzag fashion as if she is about to fall. She added that the muscles of her
lower legs are very stiff and feels weak when walking. She also says that if she closes her eyes she falls down.
However she does not report any paralysis, sensory deficits in any part of the body.There is also no hearing or
vision problems.
Eight months ago she started noticing copious amount of milk coming from her breasts even if she was not
breastfeeding or pregnant. This is associated with loss of menstrual periods and she has never had periods since
September last year.Although she was married for 3 years she had never had children. However she denies any
history of symptoms of hypothyroidism or hyperthyroidism ,use of antipsychotic drugs, visual problems or
headaches.
Review of Other Systems
Respiratory
There was no cough, fever or night sweats or difficulty in breathing
Genitourinary system
There is no history of dysuria, frequency or hematuria. There is no flank pain.
Gastrointestinal System
There is no history of weight loss, dyspepsia,jaundice,melana ,hematamesis or hematochezia.
Past medical history
She had never been hospitalized before. She did not have any chronic illnesses before such as HIV, hypertension or
sickle cell disease.She has not taken any long term medications.
Past surgical History
She had never had any operation before. She had never had any blood transfusions, or road traffic accident.
Family History
She is the second born in a family of six.The father died but her mother is alive. She does not know the cause of
death of her father. All her brother and sisters are well. There are no familial illnesses in the family like diabetes,
hypertension or sickle cell disease
Social History
She is a teacher and she is married.She lives with her husband in a permanent house in Mitoma. However she had
never had any child although she was married for 3 years.She never drinks alcohol nor smokes cigarette.
Summary
This is a 26 year old school teacher who presented with 5 month history of difficulty in walking associated with
stiffness of legs with no focal neurologic deficits.She also reports galactorrhea associated with amenorrhea for the
last 8 months.
Physical Examination
General
Clinically well looking woman lying supine in the bed with no jaundice pallour, dehydration, lymphadenopathy or
finger clubbing. However she has bilateral pitting edema. There are no peripheral stigmata of liver or heart disease.
The vital signs were:
T=36.9 in the axilla
Pulse=77/min
Blood pressure:
Respiratory rate: 21 breaths/min
Respiratory System
There are no sign of respiratory distress , chest deformities, scars or local swellings.The trachea was centrally
placed. The chest expansion was symmetrical. The vocal fremitus was normal and the percussion note was
resonant bilaterally. The chest was clear to auscultation bilaterally.There were no added sounds.
Cardiovascular system
The blood pressure was 110/70mm Hg. The pulse was of normal fullness and regular. The jugular venous
pressure was not raised. There were no chest markings. The point of maximal impulse was visible at the fifth
intercostals space midclavicular line. There were no palpable thrills or heaves. The heart sounds S1 and S2 were
heard and there were no murmurs or any other added sounds.
Abdomen
The abdomen was non distended..It was moving with respiration symmetrically. There were no visible peristalsis,
or scars in the abdomen.On palpation there were no tenderness in all of the four quadrants.There were no
organomegalies appreciated.
On auscultation the bowel sounds were present and with normal frequency.
Central Nervous System
Cranial nerves II –XII were grossly intact. . She could not sense vibration in the lower limb joints bilaterally.
Pinprick and light touch sensation were intact in both limbs. There was hypertonia in the lower limbs and the
power was 2/4. In the upper limbs the power was 4/4. There were 2+ deep tendon reflexes in the lower extrimites.
The babinski reflex was dorsiflexion.The Romberg test was positive.The gait was wide based.The coordination was
intact in both lower limbs and upper limbs.
Impression
Subacute combined degeneration of spinal cord secondary to megaloblastic anemia.
Differential Diagnosis
Tropical myeloneuropathies
Multiple sclerosis
Neurosyphilis
Investigations
Full hemogram: The peripheral blood smear showed anisopoikilocytosis There were macrocytes with
hypersegmented neutrophils. This was indicative of megaloblastic anemia.
Serum cobalamin test: not done
Schilling test: not done
Chest X ray
Treatment
The patient was started on Vitamin B12 1000-2000 mcg PO qd.
Follow Up
On 20th May 2010 the patient was discharged on oral vitamin B12.
Discussion
The neurologic complications of cobalamin deficiency is caused by the demyelination of spinal cord neurons. In
subacute combined degeneration of spinal cord, there is degeneration of both dorsal column and lateral aspect of
spinal cord which gives a picture of combined loss of proprioception and light touch sensation as well pinprick and
temperature sensation. This patient has lost the sensation of position sense which led to her inability to walk
properly. The Romberg test was positive because of her inability to sense the position of her joints.The stiffness in
her lower limbs was caused by hypertonia which is as a result of upper moton neuron lesion as evidenced by her
Babinski reflex being dorsiflexion.
The cause of vitamin B12 deficiency is usually due to pernicious anemia or gastric disease such as gastritis. A
number of intestinal disorders can also cause vitamin B12 deficiency. These include severe pancreatic disease and
small bowel diseases such as malabsorption, ileal disease (eg, including tuberculous ileitis, lymphoma, amyloid,
long-term survivors of pelvic irradiation), resection or bypass, Crohn's disease, and blind loops.
The investigations that should be done are serum cobalamin. When the deficiency is confirmed then investigations
to reveal the etiology of the deficiency is done. Schilling test is used to diagnose pernicious but it was not done in
the hospital.
References
1- www.emedicine.medscape.com
2- Goldman L. MD et al Cecil Medicine 23rd Ed. Saunders Elsavier 2007.
