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 Case Of Neuropathy  

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A 67-year-old man has had numbness and tingling in the hands and feet for 3 weeks. He lives in a homeless shelter and is well fed. He has been treated for pulmonary tuberculosis for 5 months with isoniazid, rifampin, ethambutol, and pyrazinamide. He is compliant with his medication regimen but continues to abuse alcohol. His temperature is 37 C (98.6 F), blood pressure is 134/74 mm Hg, pulse is 69/min, and respirations are 19/min. He is well nourished but depressed and irritable. There is decreased sensation to pain and touch in the hands and feet in a stocking-glove distribution. Which of the following is the most likely nutritional deficiency?

A ) Folic acid

B ) Niacin

C ) Vitamin A

D ) Vitamin B1 (thiamine)

E ) Vitamin B2 (riboflavin)

F ) Vitamin B6

G ) Vitamin B12 (cyanocobalamin)

H ) Vitamin C

I ) Vitamin D

J ) Vitamin E

K ) Vitamin K


F) Vit. B6.




I'd go with B-6 (pyridoxine) too. While alcohol abuse makes the deficiency possible, as it does the deficiency of certain other vitamins, isoniazid increases the likelihood of pyridoxine deficieny alone.






The Classic sign of B6 deficiency is increased irritability, convulsions, and peripheral neuritis. Although convulsion is not present.........
Also the patient is on isoniazid therapy


  • Thiamine (vitamin B-1) deficiency
    • Dry beriberi is characterized by severe burning dysesthesias (feet more than hands), weakness and wasting (distal more than proximal), trophic changes (shiny skin, hair loss), and acrodistal sensory loss in a graded fashion typical of dying back polyneuropathies.

    • Some patients do not become symptomatic, possibly because they are absorbing thiamine produced by bacteria in the large intestine. However, one half become symptomatic by 7 weeks; by 15 weeks, axonal changes start to appear histologically.

    • The neuropathy begins with fatigue and loss of sensation, pain, and heaviness in the legs. Then, pretibial edema develops, along with glove-and-stocking paresthesias and difficulty with tasks such as climbing stairs and standing on 1 leg.

    • If the thiamine deficiency is long standing, muscles on the dorsum of the feet atrophy and paralysis can ensue.

    • Difficulty with talking or swallowing may also be noted.


Pyridoxine (vitamin B-6) deficiency

  • The presentation includes seborrheic dermatitis, cheilosis, glossitis, nausea, vomiting, weakness, and dizziness.

  • Neurologic examination shows decreased proprioception and vibration sense with spared pain and temperature sensations; normal strength; decreased or absent Achilles reflex and decreased patellar reflex.

  • Ataxia, if present, is sensory.


B6 for sure




Fsmiling face


it is vitamin B1


B6 due to INH

alcohol mainly causes folate not vit B12 def

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