Case Studies
Case 3: A man with a six-month history of numbness in his toes and feet
A 36-year-old man presents with a six month history of evolving numbness and weakness in his toes and feet with some similar but milder symptoms in his hands. On examination he has normal cranial nerves. In the upper limbs he has weakness of finger abduction, extension and absent reflexes with loss of light touch and pin prick to the wrist. In the lower limbs he has a high stepping gait with bilateral foot drop and sensory loss to the mid shin. There is minimal wasting and absent reflexes in his legs.
Your Answer:
Correct answer: The loss of sensation and power in a symmetrical fashion of all four limbs points to a problem in the peripheral nerve.
Your Answer:
Correct answer: The evolving nature of the sensory motor neuropathy with preserved muscle bulk suggests the problem is one of slowed conduction in the peripheral nerve, rather than actual loss of nerve fibres or anaxonal neuropathy. Thus he is likely to have a demyelinating neuropathy and given it has come on over six months it is likely to be a chronic inflammatory demyelinating polyneuropathy or CIDP.
Your Answer:
Correct answer: Neurophysiology with nerve conduction studies could confirm a generalised demyelinating neuropathy with slowed conduction. CSF examination in this condition is often helpful showing increased protein with a normal glucose and cell count. Occasional nerve biopsies (of the sural or radial nerve) are needed to prove the diagnosis.