Physical Examination and Workup
Upon examination, the patient is afebrile (temperature of 97.8 °F [36.6 °C]). His heart rate is 70 beats/min and regular, blood pressure is 135/80 mm Hg, respiration rate is 18 breaths/min, and oxygen saturation is 99% on room air. He is alert and oriented to person, place, and time, but he is anxious and becomes mildly agitated when asked questions.
The cardiopulmonary examination is within normal limits. His abdomen is soft and nontender.
Cranial nerves II-XII are intact. Strength is 5/5 in both upper extremities. Strength is 3/5 in both lower extremities, with a marked decrease in strength in the toes and ankles. Impaired sensation to light touch and pinprick in a stocking-and-glove distribution is noted in the bilateral lower extremities. Deep tendon reflexes are absent in both lower extremities. Sensation is intact to light touch in both upper extremities. Reflexes are 2+ and symmetrical in both upper extremities. Reflexes are 1+ and symmetrical in both lower extremities. The patient cannot walk on heels and toes or perform a tandem gait.
Initial laboratory investigations reveal these results:
Free thyroxine level: 2.0 ng/dL (reference range, 0.8-2.7 ng/dL)
Thyroid-stimulating hormone level: 4.9 µIU/mL (reference range, 0.350-5.550 µIU/mL)
Thiamine level: 140 nmol/L (reference range, 66.5-200 nmol/L)
Red blood cell count: 3.15 × 106 cells/µL (reference range, 4.5-6 × 106 cells/µL)
Hemoglobin level: 10.9 g/dL (reference range, 13-18 g/dL)
Hematocrit: 33.1% (reference range, 40%-52%)
Mean corpuscular volume: 105 fL (reference range, 80-95 fL)
Red cell distribution width: 17.6% (reference range, 11.5%-14.5%)
Platelet count: 269 cells/mm3 (reference range, 150-450 cells/mm3)
Glucose level: 125 mg/dL (reference range, 74-106 mg/dL)
Vitamin E level: 10.9 mg/L (reference range, 5.7-19.9 mg/L)
Folate level: 10.2 ng/mL (reference range, 2.8-13.5 ng/mL)
Homocysteine level: 25.3 µmol/L (reference range, 0-15 µmol/L)
Methylmalonic acid level: 1954 nmol/L (reference range, 73-376 nmol/L)
Vitamin B12 level: 273 pg/mL (reference range, 210-920 pg/mL)
HIV, syphilis, gonorrhea, chlamydia, and Lyme disease serologies are negative. Results of urine toxicology screening (amphetamines, barbiturates, benzodiazepines, cocaine, methadone, opiates, and oxycodone) and blood alcohol testing are also negative.
The initial CT brain scan shows no hydrocephalus or cerebral or cerebellar edema and no evidence of intra-axial or extra-axial hemorrhage, midline shift or mass effect, or herniation. Figure 1 shows a CT scan with similar findings. The results of a blood smear and electromyography (EMG) and MRI studies are pending.
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