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Journal of Neurological Sciences (Turkish)
2007, Volume 24, Number 2, Page(s) 102-103
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Is Vitamin B12 Level Significant ?
Gülden Akdal
Dokuz Eylül University School of Medicine Department of Neurology
How to cite this article:
G. AKDAL: Is Vitamin B12 Level Significant ?: A Case Report. J Neurol Sci [Turk] 2007;24:102-103

How to cite this URL & PDF:
G. AKDAL: Is Vitamin B12 Level Significant ?: A Case Report. J Neurol Sci [Turk] 2007 [cited 2007 June 15];24:102-103. Available from: http://jns.dergisi.org/text.php3?id=165 PDF: http://jns.dergisi.org/pdf/pdf_JNS_165.pdf

E-mail of the corresponding author: gulden.akdal@deu.edu.tr

Vitamin B12 deficiency can present with various neurological and psychiatric manifestations such as dementia, encephalopaty, myelopathy, periferal neuropathy, optic neuropathy, depression, mania, psychosis and rarely with eye movement disorders(1,2,4).

In this issue ,there are two case reports-Güreşçi et al and Bıçakçı et al about common clinical manifestations of vitamin B12 deficiency in the elderly. Both cases have anemia, MRI hyperintensities, and they responded well to vitamin B12 injections. Only in Bıçakçı et al’s case had a follow up MRI which showed disappearance of hyperintense lesions after vitamin B12 injections. Both of the patient’s have also chronic atrophic gastritis probably the cause of vitamin B12 deficiency.

The diagnosis of vitamin B12 deficiency was clear in two cases with common manifestations. This is not always the case with the rare clinical presentations or when the blood level was in low normal range. It would be better to keep in mind that anemia does not have to accompany vitamin B12 deficiency(4). In addition to this, elevation of mean cellular volume with or without anemia represents a relatively late sign of a progressed deficiency(9). If there is a clinical suspicion for the diagnosis serum homocystein (Hyc) or methymalonic acid (MMA) levels should be checked. Hyc levels are elevated in vitamin B12, folic acid and sometimes vitamin B6 deficiency, MMA is specific to vitamin B12 deficiency.

Vitamin B12 deficiency is one of the most important problems in the nutrition of elderly since absorption of vitamin B12 is often reduced in this group mainly due to chronic atrophic gastritis(9). In elderly subjects, previous studies suggested to recognize a level of 300-350 pg/ml as a desirable status(6,9).

MRI findings in myelopaty due to vitamin B12 deficiency are also variable depending on the duration of symptoms with or without contrast enhancement(3). In the presented cases MRI showed hyperintense lesions in the spinal cord without contrast enhancement and follow of MRI in one case revealed disappearrance of the lesions. The clinical response and MRI findings to vitamin B12 therapy can be variable(5,7); the longer the neurological deficits have been present the less likely they are to resolve(4). Ideally, any neurological disorder due to vitamin B12 deficiency should resolve or at least improve with vitamin B12 therapy, but this does not always happen(1). Besides, there is not any protocol for vitamin B12 treatment. In my view, vitamin B12 injections should be given till blood normal hcy level sustained(2) especially lower than 10µmol/L. since blood vitamin B12 level does not reflect the tissue level. In addition to this, high levels of hyc has been shown to high risk for white matter damage, twofold of Alzheimer disease risk(7,9).

In conclusion, the diagnosis sometimes could be difficult and the response to therapy is not always adequate. The early diagnosis of vitamin B12 deficiency is important, because once axonal damage is established recovery will not ocur(3).

References

1) Akdal G, Yener GG, Ada E, Halmagyi GM. Eye movement disorders in vitamin B12 deficiency: two new cases and a review of the literature. European Journal of Neurology in press.

2) Akdal G, Yener GG, Kurt P, Cummings JL. Treatment responsive executive and behavioral dysfunction associated with vitamin B12 deficiency. Cognitive neuroscience forum abstract book. Cognitive forum IV, Marmaris, 2007; Vol (2): 99,

3) Bassi SS, Bulundwe KK, Greef GP et al. MRI of the spinal cord in myelopathy complicating vitamin B12 deficiency: two additional cases and a review of the literature. Neuroradiology 1999; 41:271-74

4) Healton EB, Savage DG, Brust JC, Garret TJ, Lindenbaum J Neurologic aspects of cobalamin deficiency. Medicine 1991; 70:229- 44

5) Hemmer B, Glocker FX, Schumacher M, Deuschl G, Lücking CH Subacute combined degeneration: clinical, electrophysiological, and magnetic resonance imaging findings. J Neurol Neurosurg Psychiatry 1998; 65: 822-27

6) Lindenbaum J, Rosenberg IH, Wilson PW et al. Prevalence of cobalamin deficiency in the Framingham elderly population. Am J Clin Nutr 1994; 60:2-11

7) Marie RM, Biez E, Busson P, Schaeffer S, Boiteau L, Dupuy B, Viader F Nitrous oxide anesthesia-associated myelopathy. Arch Neurol 2000; 57: 380-82

8) Obeid R, Herrman W. Mechanism of homocystein neuroxicity in neurodegenerative diseases with special reference to dementia. FEBS Letters 2006; 580: 2994-5

9) Rajan S, Wallace JI, Beresford SAA et al. Screening for cobalamin deficiency in geriatric out patients: prevalance and influence of synthetic cobalamin intake: J Am Geriat Soc 2002; 50: 624-30

10) Wolters M, Ströhle A, Hahn A. Cobalamin: a critical vitamin in the elderly. Preventive Medicine 2004;39:1256-66

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