Version July 2025
| Nutrient deficiency | Etiologies | Symptoms/signs | MRI | Diagnostic tests | Treatment (adult dosing) |
| Vitamin B12 | Vegetarian diet, pernicious anemia, stomach/small bowel surgery, Crohn disease, gastritis, medications (H2 blockers, proton pump inhibitors, metformin, colchicine), tapeworm, nitrous oxide | Subacute combined degeneration of spinal cord beginning with paresthesia and sensory ataxia (positive Romberg sign, pseudoathetosis) followed by pyramidal symptoms and signs; frequent mixture of central and peripheral sensory and motor signs due to coexisting peripheral axonal neuropathy; may be associated with optic neuropathy and cognitive impairment | T2 hyperintensity in posterior columns with inverted V sign; may extend over several levels in cervical or thoracic cord; rarely gadolinium enhancement |
| Cyanocobalamin 1000 mcg IM or deep SQ once daily for 5 days followed by 1000 mcg IM or deep SQ once monthly indefinitely; 1000 mcg orally once daily is a possible alternative chronic regimen |
| Folic acid | Alcoholism, small bowel surgery, celiac disease, inflammatory bowel disease, medications (methotrexate, pyrimethamine, trimethoprim, sulfasalazine) | Same as vitamin B12 deficiency | Same as vitamin B12 deficiency; no reports of gadolinium enhancement |
| Folic acid 3 mg orally once daily until hematologic parameters normalize and then folic acid 1 mg orally daily |
| Copper | Bariatric surgery, partial gastrectomy, zinc excess (supplements, denture cream), celiac disease, Menkes disease | Same as vitamin B12 deficiency | Same as vitamin B12 deficiency; no reports of gadolinium enhancement |
| Copper 2 to 4 mg (elemental copper) orally once daily with repeat serum copper to adjust dose; avoid zinc |
| Vitamin E | Cystic fibrosis, cholestatic liver disease, small bowel surgery, abetalipoproteinemia, ataxia with vitamin E deficiency | Sensory ataxia with absent reflexes and upgoing plantar responses, with or without pigmentary retinopathy | No characteristic spinal cord findings; MRI brain may demonstrate mild cerebellar atrophy |
| Vitamin E 300 to 1000 mg once orally daily |
