Anemia, Paresthesias, and Gait Ataxia in a 57-Year-Old Denture Wearer

Abstract

A 57-year-old man developed numbness and tingling in his toes, which progressed over 3 to 4 months to involve his legs, hands, and lower torso. He then developed trouble walking owing to imbalance and had increasingly frequent falls. His hands felt clumsy, and he began dropping objects. He reported several instances of urinary incontinence in the weeks before presentation, but no bowel symptoms. He denied focal weakness or changes in speech, swallowing, or breathing. His sisters brought him to the emergency room after a fall in which he hit his head on a kitchen stool, and he was admitted to the neurology service for further evaluation. The patient's medical history included long-standing tobacco use, chronic obstructive pulmonary disease, and low back pain. In addition, 5 months before the onset of his paresthesias, he was discovered to have a macrocytic anemia that did not respond to treatment with vitamin B12 and folate. He was subsequently treated with periodic blood transfusions. The general physical examination was unremarkable. On neurologic examination, the patient's mental status and cranial nerves were normal. A motor examination revealed spasticity without weakness in the legs. There was severe loss of vibratory and joint position sensation in the upper and lower extremities in a stocking-glove distribution; pain and temperature sensation were relatively spared. Reflexes were normal to brisk throughout, and there was no extensor toe sign. Finger tapping and toe tapping were mildly slowed. The Romberg sign was present. The patient's gait was slow, stiff-appearing, and ataxic, with a widened base and marked truncal instability. The constellation of lower extremity–predominant spasticity and proprioceptive defects suggested an abnormality in the region of the cervical spinal cord. ### QUESTIONS TO CONSIDER 1. What is in the differential diagnosis of a noncompressive myelopathy? 2. What are some causes of macrocytic anemia? 3. Could the excessive use of dental …