Unlocking the Mysteries of Subacute Combined Degeneration: The Critical Role of Early Imaging to Unsheath Mid-Pons Involvement

Subacute combined degeneration (SCD) is an uncommon neurological complication due to chronic vitamin B12 deciency, manifesting as macrocytic anemia and degeneration of the spinal cord's lateral and dorsal columns (1). It typically affects individuals over 40 years old (1), presenting with gastrointestinal, hematological, and neuropsychiatric disorders (2). Symptoms include weakness, distal tingling, numbness, irritability, apathy, drowsiness, and rapid emotional changes (1, 3). This report discusses a 69-yearold woman with SCD extending to the mid pons region. She presented with slurred speech, walking difculties, memory disturbances, defective cognition, generalized weakness, and mild limb weakness. Past medical history included hypertension, hypothyroidism, urosepsis, anemia, and incomplete B12 replacement therapy. Initial investigations revealed low serum B12 levels (90 picograms per liter), macrocytic anemia, and demyelination in the spinal cord from the ventral pons down to D12. After conrming the diagnosis through MRI, treatment included nasal spray methylcobalamin (Naso B12 - 500 mcg per spray) daily for 18 days, then every other day for 21 days, resulting in improved B12 levels (from 90 to 360 picograms) and neurological symptoms. Additional management included multivitamin infusions, Edaravone, oral folic acid, physiotherapy, and blood transfusions. The patient's neurological decits improved signicantly, and she was discharged with continued B12 supplementation and a protein-rich diet. Early detection and treatment of SCD are crucial for preventing severe neurological complications. This case underscores the importance of thorough diagnostic evaluations, including peripheral smears, hemograms, imaging studies, and electrophysiological tests, for accurate diagnosis and effective treatment.