Case Presentation
A 64-year-old Iranian man presented to our outpatient neurology clinic
with paresthesia of distal lower extremities that had started in the
left lower extremity and progressed to the right side. Within one week,
he developed asymmetrical weakness in distal lower extremities that
sequentially involved both proximal lower extremities over one month.
He also reported a loss of appetite and a 10-kg weight loss within one
and a half months.
He did not take any medications, did not smoke or use illicit drugs, and
had no history of exposure to chemicals or toxins. He had no history of
autoimmune or neoplastic diseases and his family history was
unremarkable.
Upon physical examination, he was a middle-aged man with average body
habitus. His general physical examination, including examination of the
skin and lymph nodes, was unremarkable. The neurologic exam was
significant for decreased muscle force in lower extremities that was
more severe on the left side and absent deep tendon reflexes in the
lower limbs. He had asymmetric distal hypoesthesia in both upper and
lower limbs. His first dorsal interosseous muscle was atrophic on both
sides.
The patient was admitted to the neurology ward for further workup and
emergency treatment with a clinical diagnosis of multiple
mononeuropathy. Electrophysiologic studies revealed distal axonal
sensory-motor polyneuropathy with ongoing axonal loss and multiple
mono-neuropathy. Initial lab tests revealed microcytic anemia. He
underwent chest and abdominopelvic CT with contrast and left superficial
peroneal nerve biopsy. Moreover, laboratory investigations were done in
search of an underlying systemic disease that could cause anemia and
multiple mononeuropathy (table 1).
Table 1: Table 1 Para-clinical work-up for our patient who
presented with mononeuropathy multiplex. CBC: Complete blood count;
ESR: Erythrocyte sedimentation rate; ANA: Anti-nuclear antibody; RF:
Rheumatoid factor; p-ANCA: perinuclear anti-neutrophil cytoplasmic
antibodies; CEA: Carcinoembryonic antigen; PSA: Prostate-specific
antigen; AFP: Alpha-fetoprotein; βHCG: Beta-Human Chorionic
Gonadotropin; HCV: Hepatitis C virus; HIV: Human Immunodeficiency virus;
VDRL: venereal disease research laboratory (VDRL); Pb: Lead; PPD:
Purified protein derivative; HbA1C: glycated hemoglobin; CT: Computed
tomography. Cell counts were performed using the automated cell counter
Sysmex® KP300, Biochemistry analyses were done using the Roche Hitachi
917 Rack Chemistry Analyzer, Japan; Serologic markers were checked using
the ELISA kits from AUTOBIO DIAGNOSTICS CO. and Liason Autobio A 2000
automated ELISA reader.