Case: 55-year-old Man Presents with Progressive Weakness of the Legs

by Roy Strowd, MD

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    00:02 Now let's turn to a case.

    00:03 This is a 55-year-old who presents with a three month course of progressive weakness in the legs.

    00:10 He first started to notice this at work three months ago and has become progressively weaker to the point that he is not able to work and has been using a cane for support.

    00:18 He reports sensory loss in his feet with numbness and tingling in his toes.

    00:23 Recently, he's also noticed symptoms in both hands as well.

    00:26 He denies bulbar symptoms, and examination confirms four out of five weakness that is symmetric in both legs, except three out of five strength with dorsiflexion bilaterally.

    00:37 There is subjective numbness in his feet to the toes, and deep tendon reflexes show diffuse areflexia.

    00:45 So this case is very similar to our Guillain-Barre description in case.

    00:49 However, this patient's symptoms began over three months.

    00:52 He has a slowly progressive, gradually progressive process that has all of the features of a neuropathy.

    00:59 There's symmetric weakness, sensory changes and diffuse areflexia.

    01:05 This patient underwent workup that included a lumbar puncture showing no white blood cells but elevated CSF protein of 75 and normal CSF glucose.

    01:14 So that's an inflammatory LP that's our albuminocytological dissociation.

    01:19 Nerve conduction study showed neuropathic changes with significantly reduced conduction velocity, temporal dispersion, which is the demyelinating feature.

    01:28 Absent if F-waves also at the myelinating feature, and reduced recruitment, which we see with neuropathies.

    01:35 And all of this is consistent with a peripheral nerve demyelinating disorder.

    01:40 So what's your diagnosis? Is this chronic inflammatory demyelinating polyneuropathy? Multifocal motor neuropathy? Acute intermittent demyelinating polyneuropathy? Or acute motor and sensory axonal polyneuropathy.

    01:54 Well, this presentation isn't consistent with a multifocal pattern.

    01:58 This is symmetric, so it's not multifocal motor neuropathy.

    02:01 This is not the description of AIDP.

    02:04 We see a lot of those features, however, this patient's symptoms continue to progress after eight weeks.

    02:10 And that's inconsistent with AIDP and suggestive of CIDP.

    02:15 This is not an axonal predominant process.

    02:17 We saw a lot of features of dmyelination on the nerve conduction study.

    02:21 And so that's inconsistent with acute motor and sensory axonal polyneuropathy.

    02:26 And so this is the typical presentation of CIDP.

    02:29 A chronic progressive onset, a condition over eight weeks localizing to the peripheral nerve with inflammatory changes on LP and demyelination on the nerve conduction study.

    02:41 Let's talk a little bit more about CIDP.

    02:44 What's the description? What a patient's describe? Well, it's a rare inflammatory disorder of the peripheral nerves? It is chronic and onset, with symptoms continuing to worsen after eight weeks and that's critically important in differentiating it from AIDP.

    02:57 It's slowly progressive.

    02:58 There's symmetric weakness, more than numbness.

    03:01 So there is a sensory changes but the motor changes are often out of proportion to the sensory findings.

    03:07 And areflexia is prominent.

    03:08 This is an inflammatory polyradicular neuropathy, where we see diffuse areflexia.

    About the Lecture

    The lecture Case: 55-year-old Man Presents with Progressive Weakness of the Legs by Roy Strowd, MD is from the course Chronic Inflammatory Demyelinating Polyneuropathy (CIDP).

    Included Quiz Questions

    1. Symptoms persist longer than eight weeks.
    2. Muscular weakness is symmetrical.
    3. Nerve conduction studies show a reduced conduction velocity.
    4. Areflexia is present.
    5. There are inflammatory changes seen in the CSF.

    Author of lecture Case: 55-year-old Man Presents with Progressive Weakness of the Legs

     Roy Strowd, MD

    Roy Strowd, MD

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