Subacute Combined Degeneration of the Spine: A Case Study of Delayed Diagnosis in the Emergency Department.

Subacute combined degeneration of the spine (SCDS) is a well-known disease that classically presents with progressive sensory and motor deficits and characteristic magnetic resonance imaging (MRI) findings, leading to its use as a key diagnostic tool. However, clinical and MRI findings in SCDS may be diverse, and thus, a high index of suspicion should be maintained for this disease, which can cause irreversible neurological damage if left untreated. In this article, we report the case of a 29-year-old female with significant recent life stressors and otherwise unremarkable medical history who presented with progressive weakness of the bilateral lower extremities who previously had unremarkable computed tomography (CT) and MRI completed at an outside hospital for the same symptoms, which had since continued to worsen. Her presentation at our emergency department (ED) prompted urgent evaluation with an MR cord compression study and neurology consultation. This workup resulted in an unremarkable preliminary MR read, and she was without anemia in laboratory studies. Given this, she was ultimately discharged with high suspicion for conversion disorder. After an addendum report from radiology with concern for subacute combined degeneration of the spine, she was called back to the ED where further workup revealed pernicious anemia leading to SCDS. This case highlights the importance of maintaining suspicion and avoiding premature closure in patients with reported neurological deficits.