Chapter 214. Peripheral Neuropathy

A 31-year-old man was seen for inpatient consultation for possible polyneuropathy. His history dates back 1 year when he developed asthma for the first time. At the same time, he noted progressive paresthesias that started in his feet and then progressed to involve his hands. He was unsure when the weakness in his left leg developed. He was later found to have eosinophilia and eventually treated for Churg–Strauss syndrome. He developed sepsis and required bowel resection. After his bowel resection, he noted bilateral arm weakness, which was worse on the right side. His medical course was complicated by renal failure, malabsorption, and Clostridium difficile infection currently treated with metronidazole. His examination was significant for bilateral footdrop, with significant but asymmetric weakness in the left greater than the right leg, and the right greater than the left arm. Vibration sense was absent, and joint position sense was impaired in his toes. Light touch, cold, and pinprick were diminished to his knees and elbows. He was areflexic.

The new onset of paresthesias and/or weakness in an asymmetric fashion should alert the clinician to a vasculitic process. The presence of asthma and eosinophilia with multiple mononeuropathies is diagnostic for Churg–Strauss syndrome. The presence of inflammation, fibrinoid necrosis, and hemosiderin on nerve biopsy would have been diagnostic for vasculitis. Addressing the neuropathic symptoms should lead to earlier diagnosis and treatment of the underlying disorder. This patient has multiple causes for peripheral neuropathy in addition to this vasculitis: medications (metronidazole), sepsis, malabsorption leading to vitamin deficiencies, and immobility, predisposing to compressive neuropathies.