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Washington University Experience | PERIPHERAL NEUROPATHY | 9B PERINEURITIS & PERINEURIAL PATHOLOGY | 9A0 Case 9 History
Case 9 History ---- A 56-year-old man developed bilateral progressive numbness and paresthesias of feet and hands (stocking–glove distribution) with bilateral knee pain accompanied by mild symmetrical weakness of the hands and feet over the course of 6 weeks. The patient had a history of “heavy” alcohol intake previously but quit when he developed neuropathy. Physical examination 6 months after onset showed mild wasting and weakness in distal hand and leg muscles, with stocking–glove decrease in pinprick sensation with relative sparing of vibration and joint position sensation. Ankle jerks were diminished, but other reflexes were normal. A rheumatological consultant documented diffusely inflamed joints, particularly in the distal small joints of the upper extremities, but without a specific rheumatological disease. Biochemical, hematologic, and serological investigations (including liver function, cholesterol, ESR, ANA, RF, immunoelectrophoresis, circulating immune complexes, cryoglobulins, and VDRL) were normal. CSF examination was normal. Nerve conductions and EMG showed a mild mixed but predominantly axonal sensorimotor polyneuropathy. Nerve biopsy was performed approximately 9 months after onset of symptoms and it is shown in the following images. Muscle, liver, and skin biopsies were performed and showed no abnormalities. He improved slightly with corticosteroids over the subsequent year. Steroids were discontinued after 1 year with no significant changes. About 3 years after onset of his neuropathy, he developed gradually diminishing level of alertness over several days, became near-comatose and pancytopenic and died within a few days. Autopsy demonstrated intracerebral hemorrhage, systemic sepsis, and early alcoholic cirrhosis. (This case is taken from Bilbao & Schmidt, 2015)
