(Disclaimer: This article is for scientific use only. To protect patient privacy, the relevant information in the following content has been processed)
Abstract: A 65-year-old grandfather who used to drink alcohol for more than 20 years and drank about 250g every day recently developed unstable walking and swaying. The family thought it was drunkenness and alcohol caused unstable gait, but later found that it also occurred when he did not drink, so he came to the hospital for examination. Cranial MRI and spinal cord MRI were completed, and a clear diagnosis of subacute joint degeneration of the spinal cord was made. The patient’s symptoms were relieved after medication was given, along with advice to stop drinking.
Basic information】Male, 65 years old
Disease Type】Subacute joint degeneration of the spinal cord
Hospital】Shandong Provincial Third Hospital
Date of consultation】January 2021
Treatment plan】Medication (high-dose vitamin B12 injection + vitamin B12 tablets + folic acid tablets + polysaccharide iron complex capsules) + alcohol cessation + diet adjustment
Treatment period】Hospitalization 14 days, outpatient follow-up after 1 month
Treatment effect】Stable condition, symptoms improved significantly
I. Initial consultation
The patient was thin and could smell alcohol when he came to the clinic. He complained that he had to drink about 250g of alcohol every day, but recently he had unstable walking. The examination was clear, the muscle tone of the limbs was normal, the finger-nose test and walking test were positive, and the outpatient diagnosis was: ataxia. There are many causes of ataxia, and further examination is needed to identify and treat the patient accordingly.
II. Treatment process
The patient was admitted to the hospital and underwent routine blood, stool, urine, liver and kidney function, blood lipids, blood glucose, cardiac enzymes, and anemia. The results of laboratory tests suggested moderate anemia and vitamin B12 deficiency, and the completion of cranial MRI and spinal cord MRI suggested that the upper thoracic segment of the spinal cord had dotted abnormal signals, and the enhanced scan did not strengthen, so subacute joint degeneration of the spinal cord was considered. Treatment was given to increase nutrition by abstaining from alcohol, and high-dose vitamin B12 injection was given, which was later changed to oral vitamin B12 tablets, along with supplemental folic acid tablets and polysaccharide iron complex capsules.
III. Treatment effect
After 1 week of treatment with high-dose vitamin B12 injection, vitamin B12 tablets, folic acid tablets and polysaccharide iron complex capsules, the patient’s symptoms of unsteadiness in walking were relieved, but the patient still had alcohol addiction and was instructed to abstain from alcohol during hospitalization. After 2 weeks of treatment, the patient could walk alone in a straight line, the finger-nose test was negative, and his condition improved at 14 days of hospitalization, so he was given discharge and instructed to review the patient in 1 month.
IV. Notes
I am glad that after active treatment, the patient’s symptoms improved. The patient was instructed to follow up in outpatient clinic after 1 month of discharge, while paying attention to a light diet, eating foods that can be easily digested and absorbed, paying attention to eating more green leafy vegetables, taking vitamin B12 supplements, and avoiding spicy and stimulating greasy foods. You should continue to abstain from alcohol after discharge, and your family should supervise. And regularly go to the hospital to monitor the situation of vitamin B12 index, if there is a persistent low index, you need to take oral vitamin B12 tablets for a long time to avoid the reoccurrence of the disease.
V. Personal insight
Although alcohol is good to drink, it should be controlled. Because alcohol can cause arteriosclerosis, gastritis, nerve damage and other diseases, attention should be paid to abstaining from alcohol and developing good habits. If once symptoms of ataxia appear, they should be differentiated from cranial, spinal cord and peripheral nervous system diseases, such as cerebellar infarction, spinal cord degeneration, peripheral nerve damage, etc., and formal examination should be conducted in a professional hospital to avoid delaying the disease. Usually, after active treatment, you can get good results as well as this patient.