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Neurology India, Vol. 52, No. 1, January-March, 2004, pp. 131-132 Letter To Editor A rare cause for mononeuritis multiplex Panicker JN, Nagaraja D, Ratnavalli E, Pal PK Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore - 560029 Code Number: ni04045 Sir, Paraneoplastic peripheral neuropathy is a well-described entity.[1],[2] Amongst the various manifestations, mononeuritis multiplex is relatively unusual and is usually associated with hematological malignancies. A 72-year-old man presented with eight months history of progressive symmetric burning paraesthesias over both legs. Later he noticed tingling paraesthesias over the dorsum of the right hand. Four months later he noticed weakness in the left foot in wearing slippers and clearing the ground, which gradually worsened over two months. After one month, he noticed weakness of the right hand, with difficulty in writing, holding objects and buttoning his shirt. Eight months back he developed edema of the feet. He was not a known hypertensive or diabetic. On examination, he had bilateral pedal edema and non-tender hepatomegaly extending 2 cm from the costal margin. There were no hypoesthetic patches. In the right upper limb, he had clawing of the medial two fingers, wasting of first dorsal interosseous muscle and weakness of the adductor pollicis, interossei, lumbricals and opponens digiti minimi. In the left leg he had weakness of the dorsiflexors of the ankle, evertors of subtalar joints and extensors of toes. Both ankle jerks were absent. He had sensory loss over the right little finger and medial aspect of the palm, the right medial forearm, and the lateral aspect of the left leg and dorsum of the foot including the first web space. He had left foot drop. The clinical impression was mononeuritis multiplex involving the right ulnar nerve, right medial cutaneous nerve of the forearm and the left common peroneal nerve. Prostatomegaly was evident on ultrasound scan. Nerve conduction study using surface electrodes showed low amplitude Compound muscle action potential (CMAP) of the right ulnar nerve with reduced conduction velocity and absent F waves; CMAPs were absent in bilateral common peroneal and posterior tibial nerves. CMAPs of bilateral median, radial and left ulnar nerves were normal. Bilateral median nerve Sensory nerve action potentials (SNAP) had reduced amplitude while right ulnar and bilateral sural nerve SNAPs were absent. Left ulnar SNAP was normal. Concentric needle EMG in the right abductor digiti minimi and tibialis anterior was suggestive of denervation. Biopsy of the right dorsal cutaneous nerve showed thickened perineurium and axonal breakdown without evidence of vasculitis or Hansen′s disease. Doppler scan of legs revealed deep vein thrombosis. Per-rectal fine-needle aspiration of prostate was done and examination of the smear showed adenocarcinoma of the prostate gland. The patient was referred to the oncologist and is on follow-up. Mononeuritis multiplex is characterized by subacute affection of multiple individual nerves. Common causes for this distinct clinical picture include vasculitis such as Polyarteritis nodosa and Churg-Strauss syndrome, diabetes mellitus and infections such as Hansen′s disease, Lyme′s disease and HIV infection. Malignancy is an unusual cause for mononeuritis multiplex. [1] References
Copyright 2004 - Neurology India |
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