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We report a case of a patient with cobalamin deficiency who was recommended by her primary neurologist to commence treatment with ocrelizumab, a potent anti-CD20 B-cell depleting monoclonal antibody, after being diagnosed with primary progressive MS. However, cervical spine MRI demonstrated changes classical of cobalamin deficiency including \u2018inverted V sign\u2019 signal hyperintensity and following parenteral cobalamin supplementation her neurological symptoms quickly and dramatically improved.<\/jats:p>","DOI":"10.1136\/bcr-2018-229080","type":"journal-article","created":{"date-parts":[[2019,5,15]],"date-time":"2019-05-15T06:25:14Z","timestamp":1557901514000},"page":"e229080","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Primary progressive multiple sclerosis to be treated with ocrelizumab: a mistaken case of cobalamin deficiency"],"prefix":"10.1136","volume":"12","author":[{"given":"Sydney","family":"Feldman","sequence":"first","affiliation":[{"name":"Johns Hopkins Medicine, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Salman","family":"Aljarallah","sequence":"additional","affiliation":[{"name":"Johns Hopkins Medicine, Baltimore, Maryland, USA"},{"name":"King Saud University, Riyadh, Saudi Arabia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shiv","family":"Saidha","sequence":"additional","affiliation":[{"name":"Johns Hopkins Medicine, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2019,5,14]]},"reference":[{"key":"2025082700592976000_12.5.e229080.1","first-page":"384","article-title":"Vitamin B12 Deficiency: Recognition and Management","volume":"96","author":"Langan","year":"2017","journal-title":"Am Fam Physician"},{"key":"2025082700592976000_12.5.e229080.2","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(07)70243-0"},{"key":"2025082700592976000_12.5.e229080.3","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(17)30470-2"},{"key":"2025082700592976000_12.5.e229080.4","first-page":"TJ101","article-title":"\u201cInverted V sign\u201d in sub-acute combined degeneration of cord","volume":"9","author":"Narra","year":"2015","journal-title":"J Clin Diagn Res"},{"key":"2025082700592976000_12.5.e229080.5","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp-2012-303105"},{"key":"2025082700592976000_12.5.e229080.6","doi-asserted-by":"publisher","DOI":"10.1007\/s00234-005-0016-5"},{"key":"2025082700592976000_12.5.e229080.7","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1007\/s13760-012-0115-0","article-title":"Inverted V sign in hydromyelia with Chiari type 1 malformation","volume":"113","author":"Seok","year":"2013","journal-title":"Acta Neurol Belg"},{"key":"2025082700592976000_12.5.e229080.8","doi-asserted-by":"publisher","DOI":"10.3390\/nu5114521"},{"key":"2025082700592976000_12.5.e229080.9","doi-asserted-by":"publisher","DOI":"10.1093\/fampra\/cml008"},{"key":"2025082700592976000_12.5.e229080.10","doi-asserted-by":"publisher","DOI":"10.1177\/1352458512452923"},{"key":"2025082700592976000_12.5.e229080.11","doi-asserted-by":"crossref","first-page":"987.e3","DOI":"10.1016\/j.ajem.2007.02.036","article-title":"Neurologic disease and vitamin B12 deficiency","volume":"25","author":"Svenson","year":"2007","journal-title":"Am J Emerg Med"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2018-229080","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,27]],"date-time":"2025-08-27T07:59:40Z","timestamp":1756281580000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2018-229080"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,5,14]]},"references-count":11,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2019,5,14]]},"published-print":{"date-parts":[[2019,5,14]]}},"alternative-id":["10.1136\/bcr-2018-229080"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2018-229080","relation":{},"ISSN":["1757-790X"],"issn-type":[{"type":"electronic","value":"1757-790X"}],"subject":[],"published":{"date-parts":[[2019,5,14]]}}}