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Primary progressive multiple sclerosis to be treated with ocrelizumab: a mistaken case of cobalamin deficiency
  1. Sydney Feldman1,
  2. Salman Aljarallah1,2 and
  3. Shiv Saidha1
  1. 1 Johns Hopkins Medicine, Baltimore, Maryland, USA
  2. 2 King Saud University, Riyadh, Saudi Arabia
  1. Correspondence to Dr Shiv Saidha, ssaidha2{at}


Cobalamin (vitamin B12) deficiency often manifests with neurologic symptoms and may rarely mimic multiple sclerosis (MS) among other neurological disorders. However, MRI changes associated with cobalamin deficiency are typically spinal predominant and distinct from MS-related changes. We report a case of a patient with cobalamin deficiency who was recommended by her primary neurologist to commence treatment with ocrelizumab, a potent anti-CD20 B-cell depleting monoclonal antibody, after being diagnosed with primary progressive MS. However, cervical spine MRI demonstrated changes classical of cobalamin deficiency including ‘inverted V sign’ signal hyperintensity and following parenteral cobalamin supplementation her neurological symptoms quickly and dramatically improved.

  • multiple sclerosis
  • vitamins and supplements

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  • Contributors SF wrote the manuscript with support and editing from SA and SS.

  • Funding This study is funded by National Multiple Sclerosis Society (RG-1606-08768).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.