Case Presentation:
A 24‐year‐old previously healthy man presented with sudden left‐hand weakness that lasted 6 days before complete resolution. This was followed a week later by simultaneous development of right‐hand and left‐foot weakness and numbness. He denied fever, neck trauma, seizures, headaches, visual disturbances, or incontinence. There was no history of travel, smoking, alcohol, or toxin exposure. On exam he was morbidly obese. Cranial nerves were intact. Left ankle dorsiflexion and eversion were 2/5; right wrist extension was 2/5 with weak handgrip and finger abduction. Deep tendon reflexes were brisk in the lower extremities with flexor plantar response. Fine touch was impaired over the radial aspect of the right hand, dorsum of the left foot, and left lateral leg, with intact pain, temperature, position, and vibration sensations. An extensive workup including for ESR, CRP, folate, vitamin B12, ferritin, TSH, ANA, c‐ANCA, p‐ANCA, complements, and urinalysis was normal. He tested negative for HIV, hepatitis B, hepatitis C, RPR, heavy metals, cryoglobulins, Lyme antibodies, and porphyrias. Random glucose levels were high, with an HbA1C of 8.3, and serum transaminases were mildly elevated. Chest X‐ray did not show hilar lymphadenopathy. Head CT was unremarkable. EMG findings were consistent with lower motor neuron lesion affecting the right radial and left peroneal nerve territories. Nerve conduction was normal. A diagnosis of diabetic mononeuritis multiplex was made, and the patient was started on metformin. A month later, better glycemic control was achieved and the weakness was slowly resolving.
Discussion:
Mononeuritis multiplex is a rare diabetic neuropathy defined by acute or subacute asymmetric sensorimotor paralysis of 2 or more peripheral nerves. The most common cause is vasculitis. Although DM is often included as a cause of mononeuritis multiplex, there are very few case reports in the literature. Diabetic neuropathy is known to complicate a long duration of diabetes however, some reports show that it can be associated with early diabetes or impaired glucose tolerance and may antedate the clinical diagnosis of diabetes by many years. Diabetic mononeuropathies are commonly due to entrapment and less commonly due to nerve infarction from occlusion of vasa nervosum. The pathogenesis is still not well established; however, there is increasing evidence that suggests an autoimmune basis for this condition. These patients may respond to immunosuppressive therapy in addition to strict glucose control. Other treatment modalities are still experimental. The prognosis is favorable even though it may take months or years for the neuropathy to completely resolve.
Conclusions:
Mononeuritis multiplex is a rare complication of diabetes; however, it may be the initial manifestation, as in our patient, Many reports recommend screening patients with mononeuritis multiplex for diabetes, More studies are needed to determine the pathogenesis and possible treatment strategies, as it may be reversible, especially in patients with early diabetes.
Author Disclosure:
J. Z. Dit Yafawi, none.