A 55-Year-Old Man with Neurologic, Hematologic Abnormalities

Introduction. A 55-year-old man presents with a subacute history of an unsteady, stumbling gait resulting in several falls during the last 2 weeks.

Patient history. The patient states that he is not dizzy—no sensation of the room spinning or vertigo. He does note, however, tingling sensations in both hands and feet. He believes his strength remains normal.

He has a long and complicated medical and surgical history related to severe alcoholism when he was younger. In his 30s, he had several hospital admissions for a variety of complications, most frequently gastrointestinal (GI) bleeding and acute and chronic pancreatitis. He had some form of gastric resection during that time and has had trouble maintaining his weight since. He has learned to eat small frequent meals since consuming larger portions causes GI distress. He also developed diabetes mellitus and now requires small doses of insulin, to which he is quite sensitive.

Although the patient no longer smokes, he has a 20-pack-year history. He has not consumed alcohol for 15 years.

The patient’s physical examination reveals a thin (128 pounds) man with normal vital signs. He has a broad-based, even staggering, gait. HEENT is negative for both jaundice and nystagmus. His chest is clear, and no issues with his heart. The patient’s abdomen is soft and non-tender without organomegaly. There is a large 20-cm scar in the midline of his abdomen. There is no edema. He has a broad-based ataxic gait. There is no tremor or other cerebellar signs. He has significantly diminished proprioception in both feet and, to a lesser extent, both wrists and hands, which is bilateral and symmetrical. His strength seems normal, as are his deep tendon reflexes.

The patient’s laboratory findings revealed anemia, and an examination of his blood smear confirmed severe neutropenia with hyperlobulated PMN forms present and RBC macrocytosis (Table 1).

Table 1. Laboratory findings

In response to the neurologic signs and symptoms, an MRI of the brain and spine was performed, which was negative for tumor or disc disease. However, hyperintense signals were present in the posterior and paramidline areas of the cervical cord.