Coexistent Vitamin B12 Deficiency and Hypothyroidism In a Patient Presenting with Neuropsychiatric Manifestations.

Patients with vitamin B12 deficiency are known to present with neuropsychiatric manifestations. Autoimmune origin of vitamin B12 deficiency due to pernicious anemia is relatively less common in Asians compared to certain western populations. Other autoimmune disorders including autoimmune thyroiditis may be associated with pernicious anemia. The coexistent hypovitaminosis B12 and hypothyroidism presenting with multiple level neuraxis involvement is relatively rare. Our patient, a 50 year old previously healthy male started becoming impulsive, irrational, and socially indiscreet around 4 months prior to presentation. He started talking to 'ghosts' and insisted that his house is haunted by 'spirits'. He was started on antipstchotics for his abnormal behaviour by psychiatrist only to worsen further. He was noted to have ataxic gait more prominent in the dark. He could hardly walk or feed himself without assistance. He had difficulty writing with his hand and had troublesome paraesthesias in extremities. When he presented to Neurology, he had MMSE score of 14/28. He had marked sensory ataxia, pseudoathetosis, normal motor power with exaggerated deep tendon reflexes and extensor plantars. Investigations revealed macrocytic hypochromic anemia with severely low vitamin B12 levels and hypothyroidism. Patient had positive antinuclear antibody, thyroid peroxidase and antiparietal cell antibodies. Elisa for HIV and routine blood tests including LFT, KFT were within normal limits. There was subclinical evidence of peripheral neuropathy. MRI Brain revealed cerebral atrophy and EEG showed background beta activity. Patient was started on 1000 microgam / d of parenteral vit B12 alongwith gradually escalating dose of I thyroxin. Patient showed significant signs of cognitive improvement within one week of treatment and reached MMSE score of 28/30 after 2 weeks. [ABSTRACT FROM AUTHOR]