Multineuropathy in a patient with HBV infection, polyarteritis nodosa and celiac disease

Abstract

A 53‐year‐old man came to our observation for impaired gait and painful paresthesia in his hands and feet. Three years before he suddenly presented tingling in his hands, followed, after a few months, by paresthesia in his feet, weakness of the right hand and foot and cutaneous erythema. Nearly one year after the onset, he presented left abducens nerve palsy that completely resolved in three months with steroid therapy. The patient's conditions progressively worsened and when he was admitted to our clinic the neurological examination revealed a stepping gait and severe muscular atrophy. Sensory abnormalities involved pin, light touch and vibration perception. In three years he had severe weight loss. Blood test revealed HBV infection and high levels of antibodies to transglutaminase, endomysium, and gliadin. EMG showed sensorimotor asymmetric axonal neuropathy. Nerve biopsy showed fiber loss, axonal degeneration with asymmetrical distribution and focal ischaemia. A duodenal biopsy was consistent with celiac disease. The patient was treated with high dose steroids, plasma exchange, immunoglobulin and lamivudine and began a gluten‐free diet. At discharge he could walk unassisted; sensory abnormalities were greatly reduced. One year later a new duodenal biopsy showed a complete resolution of the pathological abnormalities. Celiac disease, a chronic inflammatory intestinal disease whose pathogenesis involves a HLA DQ2‐DQ8 restricted T‐cell immune‐reaction, can be related to a higher risk of autoimmune disorders, such as insulin‐dependent diabetes or thyroid disease. We report the association of celiac disease, polyarteritis nodosa and HBV infection in a patient who developed a neuropathy and discuss the pathogenetic implications.