A 36-year-old female with a past medical history significant for alcohol abuse, anaemia, depression, pyelonephritis, and sepsis presented. The patient presented to the ED with tingling of both upper and lower extremities, lower extremity numbness, and a communicated history of recent trauma (fall from stairs). MRI during this initial visit revealed posterior column abnormalities with equivocal hyperintensities within the cord. The patient admitted to the use of nitric oxide for recreational use during the interview but denied any recent use (within 1 month).
Labs on initial admission were significant for macrocytic anaemia with a haemoglobin of 12.0 and an MCV of 104.1. Low levels of B12 were also noted, and initial MRI was within normal limits. Additionally, MCH was 34.9, MCHC was 33.5, and RDW was 82.3. Neurological exam was significant for decreased temperature and light touch sensation beginning from the lower rib cage to her toes. Reflexes were absent in both upper and lower extremities. Additionally, mild dysmetria was noted on the finger-to-nose and heel-to-shin test, bilaterally. Unfortunately, the patient's condition did not improve during hospitalization, and she presented to the ED a week later with primary complaints of knee pain associated with right lower quadrant abdominal pain that radiates to back and worse with movement as well as saddle anaesthesia. The patient's numbness had progressed.
The patients' past medical history included drug-seeking behaviour as well as alcohol abuse. She also reported a continued sensation of rolling her ankles bilaterally, altered sensation from the neck down, and an insignificant improvement in gait. Hospital course was complicated by neurogenic bladder and bowel, orthostatic hypotension, dysphagia, insomnia, leukopenia, and neuropathic, as well as nociceptive pain. Clinical workup demonstrated an MCV of 106.2, haemoglobin of 12.3, homocysteine of 10.38, and folic acid level of 10.1
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