A 55-year-old man comes to the emergency department with right foot pain. Three days ago, he noticed that he was tripping and falling frequently. He initially experienced pain and tingling in his right lower leg that progressively turned into weakness 24 hours later. Three months ago, he experienced similar pain and weakness in his left hand. His past medical history includes type 2 diabetes mellitus, hypertension, and lumbar degenerative disk disease.
His blood pressure is 150/90 mm Hg and pulse is 90/min. On physical examination, he has palpatory tenderness along the lumbar spine and trophic skin changes with stasis dermatitis in the lower extremities. Cranial nerve examination is unremarkable. Strength is 4/5 in the left hand and 3/5 in the right foot. Motor examination is normal in all other muscle groups. There is absence of pain and temperature sensation up to the knees with preserved vibration and proprioception. Reflexes are normal in the upper extremities and the knees but are absent at the ankles bilaterally. He has a steppage gait.
Which of the following is the most likely diagnosis?

Question

A 55-year-old man comes to the emergency department with right foot pain.  Three days ago, he noticed that he was tripping and falling frequently.  He initially experienced pain and tingling in his right lower leg that progressively turned into weakness 24 hours later.  Three months ago, he experienced similar pain and weakness in his left hand.  His past medical history includes type 2 diabetes mellitus, hypertension, and lumbar degenerative disk disease.
His blood pressure is 150/90 mm Hg and pulse is 90/min.  On physical examination, he has palpatory tenderness along the lumbar spine and trophic skin changes with stasis dermatitis in the lower extremities.  Cranial nerve examination is unremarkable.  Strength is 4/5 in the left hand and 3/5 in the right foot.  Motor examination is normal in all other muscle groups.  There is absence of pain and temperature sensation up to the knees with preserved vibration and proprioception.  Reflexes are normal in the upper extremities and the knees but are absent at the ankles bilaterally.  He has a steppage gait.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient with a history of diabetes mellitus presents with complaints of abrupt onset of asymmetric, multiple peripheral neuropathies suggestive of mononeuritis multiplex. Mononeuritis multiplex is a painful, asymmetrical, sensory and motor peripheral neuropathy. It affects 2 or more nerves in different parts of the body and is most common in patients with vasculitides, connective tissue diseases, or systemic disorders such as diabetes mellitus. Multiple long nerves (eg, sciatic, peroneal, tibial, radial) in random areas of the body are commonly affected first. As the disease progresses, neuropathy can become more confluent and symmetrical. Patients typically present with complaints of pain, numbness, dysesthesias, or loss of reflexes. Some patients may initially present with foot drop (steppage or foot-slapping gait) or wrist drop. Clinical symptoms are sufficient to make the diagnosis. However, nerve biopsy (which shows epineurial perivascular inflammation) or electrodiagnostic studies can be performed if there is insufficient evidence. Treatment includes controlling the primary disease process. In patients who remain symptomatic despite adequate control of primary disease, over-the-counter analgesics, tricyclic antidepressants, and anticonvulsant drugs (eg, gabapentin) can be used. Most patients recover without long-term consequences, but some may have muscle wasting and irreversible damage due to nerve infarction. (Choice A) Amyotrophic lateral sclerosis is a progressive neurodegenerative disease that causes destruction of the upper and lower motor neurons in the brain and spinal cord. Sensory symptoms are absent. (Choice B) L5 radiculopathy is the most common lumbosacral radiculopathy. Patients present with back pain that radiates down the lateral surface of the leg into the foot. Hand symptoms are not seen in L5 radiculopathy. (Choice C) Patients with lacunar strokes may present with sensory or motor symptoms, hemiparesis, or dysarthria. This patient has predominantly lower motor neuron signs (ie, absent reflexes). (Choice E) Multiple sclerosis usually occurs in patients age 15-50 years. Patients commonly present with 2 or more distinct episodes of central nervous system dysfunction with partial or complete resolution. Multiple sclerosis does not affect the peripheral nervous system. Educational objective: Mononeuritis multiplex is a painful, asymmetrical, sensory and motor peripheral neuropathy. It affects 2 or more nerves in different parts of the body and is most common in patients with vasculitides, connective tissue diseases, or systemic disorders such as diabetes mellitus. __________ References: Mononeuritis multiplex in diabetes mellitus: evidence for underlying immune pathogenesis. (http://www.ncbi.nlm.nih.gov/pubmed/12754358)

A 55-Year-Old Man Comes to the Emergency Department with Right