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A 58-year-old woman developed painful toes while under investigation for dyspnea. She was anemic with vitamin B12 and iron deficiency and replacement therapy was instituted. She had undergone partial gastrectomy 20 years previously for peptic ulcer disease and had not required vitamin B12 replacement. CT of the chest showed an infective left mid-zone pulmonary lesion. Six months later she developed numbness and paresthesiae of both feet, which spread to mid-calf level. Three months later she became unsteady and then developed tingling in her fingers and clumsy hands. She had right-sided sciatica and previously smoked 40 cigarettes/day.
On examination cranial nerves were normal. There was mild gait ataxia. Right abductor pollicis brevis (APB) and dorsal interossei of both hands were wasted. Tone was normal with no fasciculations. Shoulder abduction, APB, finger abduction, hip flexion, knee flexion, and dorsiflexion of the ankle were mildly weak bilaterally. There was no upper limb ataxia. Left heel-shin testing was impaired. All reflexes were present except for the right ankle jerk. The left plantar reflex was …
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