Report a case of lower limb spasms in a patient with hemifacial spasms, vitamin B12 and D deficiency

Demyelination resulting from vitamin B12 or D or combined deficiencies represents a secondary HFS etiology in addition to vascular compression. Vitamin B12 deficiency can cause myelopathy, neuropathy and dementia, but can have more discrete  neuromuscular manifestations including cramps.

Case report and Literature review.

A 65-year old female with a history of hemifacial spasms, type 2 diabetes mellitus and chronic low back pain presented to the emergency department with an 8-month history of painful bilateral calf and thigh muscles spasms with a nocturnal preponderance. She was treated with diazepam and referred to the outpatient neurology clinic. Upon evaluation in the clinic, her examination was remarkable for frequent mild to moderate right upper and lower facial spasms. Gait was antalgic with palpable tenderness along the left lateral thigh. Her MRI brain and MR angiogram of the Circle of Willis and carotids showed a branch of the right MCA in close proximity to the cisternal right facial nerve without definite contact. Her facial spasms had responded well to botulinum toxin injections. Laboratory investigations revealed vitamin B12(212 pmol/) and D (19 nmol/l) deficiencies as well as increased serum parathormone (89 ng/l) but normal serum and ionized calcium levels.

Full resolution of the lower limb spasms was reported within 4 weeks of initiation of vitamin B12 1000 mcg daily supplementation with normalization of serum levels to 625 pmol/l at 6 weeks. Vitamin D3 supplementation was also initiated. There was no obvious change in the severity or frequency of the hemifacial spasms.

It is important to consider vitamin deficiencies especially vitamin B12 in patients presenting with leg spasms and cramps. This is a treatable and reversible etiology compared with other cramping syndrome which are often refractory to therapy.