0:01

This was a case with a fascinating history.

0:04

It's a 70-year-old woman who was having

0:07

difficulty with ambulation, secondary to loss

0:11

of position sense on clinical evaluation.

0:15

She was using a walker and was

0:17

having episodes of falling.

0:20

On the MRI scan, looking at the sagittal

0:26

STIR imaging, we were initially sort of

0:28

fascinated by this disc herniation, which was

0:31

migrating behind the inferior endplate of C4.

0:37

Uh, and on the T2-weighted scan, you can see,

0:42

uh, the degenerative disc disease.

0:46

I'm going to magnify this a little bit more

0:48

and bring it back down so we can look at that

0:51

cervical spine a little bit more closely.

0:54

Not all that dramatic on

0:56

the T2-weighted images here.

0:59

If we look at the axial T2-weighted

1:02

scan, we were struck by the persistent

1:06

bright signal intensity in the central

1:09

posterior portion of the spinal cord.

1:13

Let me magnify that up so that even the

1:17

person behind you can see the case and

1:20

I'm gonna make it a little bit more contrasty.

1:24

So what we're looking at is the

1:26

bright signal in the midline of the

1:28

posterior aspect of the spinal cord.

1:31

So let's focus right here.

1:33

And this corresponds to some small area of

1:37

bright signal intensity seen in the posterior

1:40

spinal cord at the upper cervical region.

1:44

I think it's actually better seen

1:45

on the, uh, sagittal STIR image.

1:49

Let me just bring that back down

1:54

and magnify.

1:55

And then maybe it is a little bit more convincing.

1:59

Just scroll here to another level.

2:03

So what we're looking at is the

2:05

bright signal intensity in the

2:06

posterior aspect of the spinal cord.

2:09

And on either side of the midline

2:12

affecting the posterior columns.

2:14

So this patient had B12 levels

2:16

drawn and they were normal.

2:18

Turned out that when further serologic

2:21

testing was performed, we did discover

2:25

that this patient had copper deficiency.

2:29

The etiology for this copper deficiency is what

2:31

I find the most fascinating and the clinical

2:34

note said that she had copper deficiency,

2:38

secondary to zinc toxicity

2:42

due to denture cream overuse.

2:45

So apparently the zinc in the denture cream was

2:50

being swallowed and absorbed and was binding or,

2:55

or, uh, competing with the copper uptake such that

3:00

she developed copper deficiency as the etiology

3:04

for her subacute combined, uh, degeneration.

3:08

So this was not from B12 deficiency.

3:10

This was actually from copper deficiency.

3:14

Folate deficiency and nitrous oxide

3:16

toxicity are the other etiologies

3:19

potentially for this same abnormality.

3:22

So as you scroll the axials, maybe you're, it's

3:25

a little bit more convincing that there's always

3:27

this persistent bright signal intensity in the

3:30

paramedian region of the posterior columns.

3:33

And this patient was pretty

3:34

much devastated by that.

3:36

And, uh, despite copper replenishment,

3:40

still was Walker dependent.