Bilateral Hand Weakness and Numbness

Abstract

HISTORY: 51year old right-handed male who had 3 months of tingling in his right hand's fingers. He rapidly developed weakness of the boht hands in the next few months. His arms felt "heavy" and he was having difficulty performing daily activities such as dressing himself, shaving, and eating. By presentation, the symptoms were equal in both hands/arms. He also endorses a 5 kg weight loss. The patient smokes about 1 PPD since age 16 and drinks alcohol socially. He worked as a materials handler at a federal mint until a few months ago, when he stopped working due to hand weakness. PHYSICAL EXAMINATION: CN II-XII were intact. There was noticeable atrophy in both hands with occasional fasciculations. Strength in the proximal arms was normal. He had diminished 2-3/5 strength in finger extension, 3-4/5 in finger abduction, 4/5 in finger flexion, and 4/5 in thumb abduction. Lower extremities had full strength. Reflexes were 2+ and symmetric. There was decreased pinprick sensation in the lower forearms and hands and decreased vibratory sensation in both hands. DIFFERENTIAL DIAGNOSIS: 1. Inflammatory/immune polyneuropathy 2. Brachial plexopathy 3. Paraneoplastic process 4. Vasculitis 5. Cervical spine disease with ulnar neuropathy TEST AND RESULTS: Blood work: B12, ESR, RF, ANA, HCV, pareneoplastic panel, and TSH are unremarkable. CSF with slightly high protein, but otherwise normal.No systemic markers of vasculitis. MRI: Moderate to severe spinal stenosis at C6/7 with bilateral neuroforaminal narrowing (symptoms do not correlate to this level) Moderate spinal stenosis at C5/6 and C7/T1 No abnormality of either brachial plexus Degenerative changes in lower c-spine with moderate canal and neuroforaminal stenosis EMG: Decreased ulnar sensory and motor function; median and radial nerves normal Severe chronic partial denervation in 1st dorsal interosseous and flexor digitorum profundus Other C7-innervated muscles showed mild chronic partial denervation FINAL/WORKING DIAGNOSIS: Lewis-Sumner Syndrome (variant of chronic inflammatory demyelinating polyneuropathy) TREATMENT AND OUTCOMES: 1. Oral prednisone. Follow-up in 4 months showed no further progression of peripheral neuropathy 2. Steroids will be continued for 3 months, if no evidence of axonal regeneration then IV gamma globulin will considered 3. Physical therapy