430 ) A 70 year-old man is evaluated in your office for fatigue and unsteady gait. His symptoms started 2 months and progressively increasing. He also reports numbness and paresthesias in his bilateral lower extremities. His other issues include ill-fitting dentures for which he used dental adhesives for past 2 years. His past medical history is also significant for gastric bypass surgery approximately 8 years ago for recurrent peptic ulcer disease. He receives Vitamin B12 Subcutaneously every 3 to 6 months. On presentation, he is confined to a wheelchair. Neurological examination revealed markedly decreased vibratory sensation and proprioception in the lower extremities bilaterally. Both pin-prick and light touch sensations were moderately reduced below the knees. Muscle power, bulk, tone, and reflexes were normal. Rest of his physical examination is normal. Laboratory investigations reveal hemoglobin = 8.5 g/dL, MCV= 74 fL, MCHC = 33.6gm/dl, leukopenia with a WBC =1.9k/µl and absolute neutrophil count = 475 cells/µL. His platelet count, iron studies, folate and syphilis serologies were within normal limits. Vitamin B12 was 900pg/ml ( N = 180 to 400pg/ml) . Serum Zinc level is 600µg/dl ( Normal is 70-150 µg/dl).
Which of the following is most appropriate at this time?
A) Check Methyl Malonic Acid Level
B) Start Penicillamine
C) Bone Marrow Biopsy
D) CT scan of the Head
E) Discontinue dental adhesives and check Copper levels
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