Volume 5 • Issue 4 • 1000194 J Psychol Psychother ISSN: 2161-0487 JPPT, an open access journal Research Article Open Access Kumar et al., J Psychol Psychother 2015, 5:4 http://dx.doi.org/10.4172/2161-0487.1000194 Case Report Open Access Psychology & Psychotherapy J o u r n a l o f P s y c h o l o g y & P s y c h o t h e r a p y ISSN: 2161-0487 Correlation of Clinical and MRI Features of Neuropsychiatric Manifesta- tions in Sub-acute Combined Degeneration of Spinal Cord: Neurological Syndrome Associated with Vitamin B12 Deficiency Ravinder Kumar 1 *, Kapil Vyas 1 , Gagan Jaiswal 1 , Abhishek Bhargava 1 and Jyoti Kundu 2 1 Department of Radio Diagnosis, Geetanjali Medical College and Hospital/ Geetanjali University, India 2 Department of Prosthodontics, Geetanjali Dental and Research Institute/ Geetanjali University, India Abstract Vitamin B12 or cynacobalamin is an important water soluble vitamin which plays a key role in erythropoiesis, proper nervous system functioning and for the metabolism of carbohydrate, fat and protein. Patients with cynacobalamin defciency may present with haematological, gastro-intestinal, oral, dermatological, psychiatric and neurological disturbances. We present a case of sub-acute combined degeneration (SACD) of spinal cord in a forty- nine year old female presenting with one month history of progressive symptoms of lower limb paraesthesia, sensory defcit, psychotic symptoms and postural instability. This case report is unusual as it elucidates the characteristic triad, i.e., haematological, psychiatric and neurological symptoms in sub-acute combined degeneration of spinal cord (SACD) associated with B12 defciency, correlation of its clinical manifestations, electrophysiological signs, laboratory investigations ( especially biomarkers of B12 status) and spinal magnetic resonance (MR) imaging in establishing the diagnosis, treatment outcomes, and potential therapeutic relevance of vitamin B12 replacement therapy in symptoms remission. Keywords: Vitamin B12; Dementia; Neuropathy; Spinal MRI; Sub- acute combined degeneration. Introduction Vitamin B12 or cynacobalamin is an important water soluble vitamin which plays an important role in erythropoiesis, proper nervous system function and for the metabolism of carbohydrate, fat and protein. Vitamin B12 (cyanocobalamin) is found essentially in animal products including meat, fsh, eggs and dairy products. Other dietary sources include B12 containing fortifed plant products such as cereals, plant based milks, soy products and fortifed yeast extract [1,2]. Patients with cynacobalamin defciency may present with haematological, gastro-intestinal, oral, dermatological, psychiatric and neurological disturbances. Tis case report illustrates the severity of B12 defciency, causes, clinical manifestations, treatment outcomes, biomarkers of B12 status and potential therapeutic relevance of vitamin B12 replacement therapy. Te purpose of this article is to highlight neuropsychiatric symptoms in B12 defciency associated SACD, correlation of its clinical manifestations, electrophysiological signs, laboratory investigations and spinal magnetic resonance (MR) imaging, high index of suspicion for its early diagnosis as delay in treatment can lead to poor neurological recovery due to this subtle vitamin defciency. Case Presentation A 49-year-old female was referred to our hospital with two month history of gradual progressive dementia, followed by social withdrawal, mood swings and apathy. One month ago, abrupt onset of tingling in the toes, pins and needle sensation of lower limbs up to trunk started. She also complained of difculty in walking and progressive postural instability. Te patient presented with confusion, mood lability, memory and attention impairment and disorientation in time. Te patient’s neuropsychological profle revealed impairment of her attentional, reasoning and executive functions along with reduced performance at the delayed free recall of the Rey’s list [Rey auditory verbal learning test (RAVLT)]. Te score of the Raven’s matrices [Raven’s coloured progressive matrices (RCPM)], Word fuency test, Weigl’s sorting test (WST) and Mini mental state examination (MMSE) was also impaired. *Corresponding author: Ravinder Kumar, Department of Radio Diagnosis, Geetanjali Medical College and Hospital/ Geetanjali University, India, Tel: +919571218953; E-mail: kundu19@yahoo.co.in Received May 18, 2015; Accepted July 14, 2015; Published July 21, 2015 Citation: Kumar R, Vyas K, Jaiswal G, Bhargava A, Kundu J (2015) Correlation of Clinical and MRI Features of Neuropsychiatric Manifestations in Sub-acute Combined Degeneration of Spinal Cord: Neurological Syndrome Associated with Vitamin B12 Defciency. J Psychol Psychother 5: 194. doi: 10.4172/2161- 0487.1000194 Copyright: © 2015 Kumar R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Te score of the MMSE was 23. A careful history revealed that psychotic or cognitive symptoms preceded neurological symptoms. (Gradual progression of dementia and irritability started two months ago). Te patient did not report any signifcant past history or family history of psychiatric illness, gastrointestinal symptoms, pre-existing diabetes mellitus, alcohol addiction, any medications which can decrease serum Vit. B12 level or Nitrous oxide exposure. But, the patient revealed strict preference for vegetarian diet and consumed lentils (Kesari). She had no fever, weight loss, visual or bulbar symptoms, sphincter incontinence or pain in the spine or limbs. On systemic examination, vital signs were found to be normal but mild anaemia and glossitis was noticed. Deep tendon refexes were normal. Sensation and joint position sense of the distal part of lower extremities was impaired. Tough power and tone of lower limbs were normal but vibration was impaired over ankle and toes. Romberg’s sign was positive but Babinski’s sign and Lhermitte’s sign were absent. Gait was evaluated as ataxic. All laboratory results were within normal limits except vitamin B 12 , which was extremely low: the patient had a serum level of 30 pg/mL (normal range: 200 to 835 pg/ mL). Peripheral blood smear examination showed anisopoikilocytosis with macrocytosis blood picture. Hemoglobin was 11.0 gm/dl with raised MCV (107.5 f). Random Blood Sugar, TSH, folate, LFT, LDH, creatinine were all normal. HIV and VDRL- TPHA test were negative. Titers of antibodies specifc for parietal cells were in the normal range.