A 35 year old woman presents with a tingling sensation in both hands and feet for 2 months, in association with worsening numbness. No other symptoms were present.

Her medical and surgical histories are unremarkable, while her family history is only significant for a brother who died in childhood from Menkes disease.

Currently, she is not on any medications. She is a strict vegan, and does not drink or smoke.

A complete blood count is significant for a Hb of 9.3 g/dL, erythrocyte count of 3.1× 10^12/L, and a MCV of 126 fL. A fasting plasma glucose level is 84 mg/dL.

Select Relevant Investigations
Peripheral Blood Film


The peripheral blood film demonstrates marked macrocytosis and anisopoikilocytosis, along with some hypersegmented neutrophils.
MRI Cervical & Thoracic Spine


The posterior columns of the cervical and upper thoracic spinal cord show bilateral symmetrical hyperintensity in T2-weighted images, and hypointensity in the T1-weighted films.
Nerve Conduction Studies


Nerve conduction studies of both the upper and lower limbs reveal no abnormalities.
Serum Vitamin B12 + Folate + Copper


Vitamin B12: 110 pg/mL (200-800)
Folate: 22 ng/mL (2-20)
Copper: 117 μg/dL (80-155)

Select Relevant Management
Parenteral Copper
Parenteral Vitamin B12
Folate Supplementation
Vitamin B12 Fortified Foods