A 65-year-old man comes to the office due to tingling, numbness, and burning pain in his left hand for several weeks. He also has similar symptoms in his right hand but to a lesser extent. The patient has end-stage renal disease due to hypertension and, for the past 2 years, has been receiving hemodialysis through an arteriovenous fistula of the left arm. Symptoms worsen during hemodialysis sessions. The patient has no symptoms in the legs. He has no muscle weakness, headache, vision changes, speech changes, or swallowing difficulty. Which of the following is the most likely diagnosis?

Question

A 65-year-old man comes to the office due to tingling, numbness, and burning pain in his left hand for several weeks.  He also has similar symptoms in his right hand but to a lesser extent.  The patient has end-stage renal disease due to hypertension and, for the past 2 years, has been receiving hemodialysis through an arteriovenous fistula of the left arm.  Symptoms worsen during hemodialysis sessions.  The patient has no symptoms in the legs.  He has no muscle weakness, headache, vision changes, speech changes, or swallowing difficulty.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient with end-stage renal disease (ESRD) has tingling, numbness, and burning of the bilateral hands that worsen during hemodialysis, suggesting carpal tunnel syndrome (CTS). CTS occurs due to compression of the median nerve as it passes through the carpal tunnel in the wrist. carpal tunnel CTS is the most common mononeuropathy in patients on hemodialysis, with up to a third reporting symptoms. The etiology in this population is multifactorial. The most common cause is likely dialysis-related amyloidosis, in which inflammation stimulates the formation of beta-2 microglobulin. This is inadequately cleared and deposited as amyloid within the carpal tunnel. Other contributing factors include increased venous pressure during hemodialysis, blood tracking (through fascial planes) from the fistula into the carpal tunnel during vascular access, and deposition of calcium phosphate in the tunnel, all of which worsen extrinsic compression of the nerve. In addition, vascular steal through the fistula may lead to ischemic neuropathy. Manifestations include pain and paresthesia involving the first 3 digits and the radial aspect of the fourth; however, patients may also have referred pain throughout the hand. Symptoms typically worsen during dialysis and are more severe in the arm with vascular access (eg, fistula, graft). In all forms of CTS, including that caused by dialysis-related amyloidosis, symptoms are frequently reproducible with provocative measures. The diagnosis is usually made clinically but can be confirmed with electrodiagnostic studies. provocative measures (Choice B) Cervical myelopathy is characterized by slowly progressive weakness, numbness, and ataxia involving the upper and lower extremities. It would not be expected to cause pain that worsens with hemodialysis. (Choice C) Subclavian steal syndrome causes exercise-induced arm pain, paresthesia, coolness, and color change. It typically affects the entire arm, not just the hands, and bilateral symptoms would be unexpected. (Choice D) Hypocalcemia can result in hand cramping and paresthesia but typically occurs in association with perioral numbness and tetany. It would not usually be more severe unilaterally or worsen during hemodialysis. (Choice E) Uremic polyneuropathy is common in patients with ESRD but causes progressive pain and paresthesia in the feet, not the hands. Because it is due to uremia, the polyneuropathy typically resolves when dialysis is initiated. Educational objective: Carpal tunnel syndrome is the most common mononeuropathy in patients with end-stage renal disease on dialysis. It is characterized by pain and paresthesia in the lateral hand; symptoms typically worsen during dialysis and are more severe in the arm with vascular access.

A 65-Year-Old Man Comes to the Office Due to Tingling