Cobalamine deficiency associated with neuropathy and oral mucosal melanosis in untreated gluten-sensitive enteropathy

A 32-year-old woman was admitted with complaints of difficulty in walking and hypoaesthesia and tingling in her legs. She had short stature and brown-black hyperpigmentation, cheliosis, dental irregularities and scars in the axillary regions. Neurological examination revealed mild, symmetric, predominantly distal weakness of the legs; deep tendon reflexes were depressed. There was glove-and-stocking decrease in pinprick and temperature perception but proprioception and light touch were normal. Investigations established a diagnosis of celiac disease; her neurological features improved on gluten-free diet, but oral pigmentation persisted.