Vasculitic neuropathy

Vasculitis is a primary phenomenon in autoimmune diseases such as polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and essential mixed cryoglobulinemia. As a secondary feature vasculitis may complicate, for example, connective tissue diseases, infections, malignancies, and diabetes. Vasculitic neuropathy is a consequence of destruction of the vessel wall and occlusion of the vessel lumen of small epineurial arteries. Sometimes patients present with nonsystemic vasculitic neuropathy, i.e., vasculitis limited to peripheral nerves and muscles with no evidence of further systemic involvement. Treatment with corticosteroids, sometimes in combination with other immunosuppressants, is required to control the inflammatory process and prevent further ischemic nerve damage.

Mononeuropathy multiplex in a patient with chronic active hepatitis B

Background

Mononeuropathy multiplex is a rare complication during the course of chronic hepatitis B, despite various neuropathies following acute hepatitis B having been reported previously.

Case Report

A 30-year-old man presented with sensorimotor symptoms in multiple peripheral nerves. The serological tests for hepatitis were consistent with chronic active hepatitis B. After treatment with oral prednisone combined with an antiviral agent, the sensory and motor symptoms improved and hepatitis B virus replication was reduced.

Conclusions

We suggest that chronic immune-mediated neuropathy associated with hepatitis B virus infection should be considered in the differential diagnosis of patients with hepatitis B.

Severe Functional Loss of the Hand due to Necrotizing Fasciitis with Underlying Vasculitis Neuropathy

A 72-year-old man presented with an erythematous, painful, swollen, and blistering left hand associated with a systemic fever. The patient was diagnosed with microscopic polyangiitis and was receiving steroid therapy from a year before the incident. Based on a clinical diagnosis of necrotizing fasciitis, emergency surgery was performed within 2 days after the onset. β-Hemolytic Streptococcus group A was isolated from a culture of the blood and wound. Radical debridement and high-dose penicillin and clindamycin therapy successfully saved the patient's life and affected limb except for the second finger on his left hand, which was completely necrotic. However, the function of the left hand was seriously decreased and did not recover. The important point to note in this case was the preexisting vasculitis neuropathy due to microscopic polyangiitis. The severe postoperative dysfunction of the hand was considered to be due to ischemic neuropathy that was aggravated by compartmental syndrome and microvascular thrombosis. In conclusion, necrotizing fasciitis of an extremity with underlying vasculitis neuropathy can lead to a poor functional prognosis of the limb.

Pure Neuritic Leprosy with Bilateral Foot Drop and Central Nervous Involvement: A Clinical, Electrophysiological, and MR Correlation

Background

Central nervous system (CNS) involvement in leprosy is sparsely documented. Neurophysiological tests and magnetic resonance imaging (MRI) helps in demonstrating CNS involvement in the patient of pure neuritic leprosy.

Objectives

To demonstrate CNS involvement in pure neuritic leprosy.

Methods

Detailed clinical presentation and skin lesions were evaluated. Sural nerve biopsy, MRI diffusion tensor imaging of spinal cord and optic nerve were performed. Visual evoked potential and tibial somatosensory evoked potential were done. Their clinical, electrophysiological, and MRI were done at follow-up visits.

Results

We report three patients of pure neuritic leprosy with bilateral foot drop as the initial presentation. MRI T2W sequence of cervico dorsal cord showed dorsal column hyperintensity in two patients. Diffusion-weighted MR revealed decrease fractional anisotropy and an increase in the apparent diffusion coefficient. Similar findings were also noted in the optic nerves. The patients were managed with multidrug therapy multibacillary regimen and steroid in tapering dose. At follow-up, they showed clinical improvement in vision and power of ankle dorsiflexor.

Conclusions

Patients of pure neuritic leprosy may manifest with bilateral foot drop with the involvement of posterior column and cranial nerves.

[Mononeuropathy multiplex caused by cutaneous arteritis diagnosed by skin biopsies for emerging atypical erythema on upper limbs following neurological symptoms: a case report]

A 33-year-old female was admitted to our department complaining of multifocal paresthesia and weakness of the upper and lower extremities that had developed over the previous three months. She had also been undergoing treatment for atopic dermatitis with dupilumab, an anti-interleukin 4/13 receptor antibody. A nerve conduction study revealed multifocal axonal sensorimotor neuropathy of bilateral limbs. On admission, a small erythema appeared on her right forearm, but it was atypical for vasculitic skin lesions due to its location and time course. Nonetheless, a biopsy revealed medium-sized vessel vasculitis. The patient was therefore diagnosed with vasculitic neuropathy caused by cutaneous arteritis. Methylprednisolone pulse therapy with prednisolone and azathioprine markedly improved her symptoms. A skin biopsy is useful when mononeuropathy multiplex is suspected, even if the skin findings are atypical for vasculitic rash.

Unveiling the Uncommon: A Case of Eosinophilic Granulomatosis With Polyangiitis Featuring Atypical Presentation and Diagnostic Challenges

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare necrotizing vasculitis affecting small- to medium-sized vessels that can manifest in a multisystemic manner. While the classic triad of rhinosinusitis, asthma, and eosinophilia is commonly associated, it is essential to recognize that these features are not mandatory for diagnosis. We present a case of a 61-year-old woman with a unique EGPA manifestation who was hospitalized because of a seven-month history of weight loss, asthenia, epigastric abdominal pain, peripheral eosinophilia, and paresthesia in the left feet and hand. Notably absent were typical pulmonary alterations such as asthma or nasal polyps. Respiratory function tests yielded normal results, and imaging studies revealed no granulomas or signs of vasculitis. Instead, she exhibited mononeuritis multiplex and constitutional symptoms. Diagnostic criteria were met, including positive anti-neutrophil cytoplasmic antibody (ANCA) with myeloperoxidase (MPO) pattern and severe axonal neuropathy confirmed by nerve biopsy. Treatment commenced with prednisolone and then with methotrexate. This case underscores the diversity of EGPA presentations and the importance of considering atypical symptoms for accurate diagnosis and timely intervention. Despite the absence of classic features, our comprehensive approach facilitated prompt recognition and effective management.

A Case Report of Systemic Lupus Erythematosus Presenting as Isolated Mononeuropathy Multiplex

Mononeuropathy multiplex is a pattern of progressive sensory and motor deficits in the distribution of two or more peripheral nerves. The differential for mononeuropathy multiplex includes vasculitis, autoimmune disorders, infectious diseases, sarcoidosis, amyloidosis, cryoglobulinemia, and paraneoplastic disease. We present a case of a 42-year-old woman with hypothyroidism who presented with 1 week of ascending numbness and weakness, persistent fevers, and 3 months of constant burning pain in both feet. Her neurologic exam was notable for asymmetric weakness, loss of sensation, and diminished reflexes of her lower extremities. Other than mild fever and tachycardia, there were no systemic exam findings. Her laboratory workup was significant for elevated inflammatory markers, positive ANA, anti-ribonucleoprotein, smooth muscle antibody, and lupus anticoagulant, high anti-dsDNA titers, and low complement levels. An MRI of her lumbar spine was negative for lumbosacral nerve root pathology. Cerebrospinal fluid studies demonstrated normal cell counts, glucose, and protein and no evidence of infection. An electromyography (EMG) and nerve conduction studies (NCS) demonstrated asymmetric involvement of multiple individual peripheral nerves. Given the patient's symptoms, asymmetric exam findings, laboratory results, and EMG/NCS findings, she was diagnosed with mononeuropathy multiplex secondary to systemic lupus erythematosus (SLE) and started on steroid and immunosuppressant therapy with symptomatic improvement. Overall, this case illustrates the unique presentation of mononeuropathy multiplex as the initial manifestation of SLE. The identification of this specific type of neuropathy may play a crucial role in the prompt diagnosis of SLE and timely initiation of treatment, preventing further complications of the disease.